Archive for July 11, 2015

Our National Blindspot

Congratulations.  You have just been appointed Surgeon General of the United States Public Health Service—top dog and top doc over the Centers for Disease Control and Prevention in Atlanta.   Here’s the catch: The POTUS told you in his Oval Office chat before his announcement that your survival in the job depends on your choosing one issue to target that will dramatically drop a) chronic disease rates for diabetes, heart, and lung diseases, b) severe mental illness rates, c) substance abuse rates, d) crime rates, and e) stay budget neutral.  The POTUS wants a bigger bang for the buck than we got with the last target issue, smoking, thirty years ago.  What’s your magic bullet, Surgeon General?  He generously gave you a week to choose.

Before you resign for the familiar comforts of civilian life, you scribble a list to talk over with your eager advisers: obesity, gun violence, heroin, diabetes, Alzheimer’s, cancer.  The list is too short. The data don’t fit his criteria.  POTUS is a dreamer.  There is no magic bullet.  Your advisers agree with you.  They advise you this is just the first of what you can expect to be a series of setups to test your political mettle.

You sleep badly that night, but like a good soldier you show up at work the next morning.  There on your desk is a worn and marked copy of The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma by Bessel van der Kolk, MD (2014).  A bookmark between pages 346 and 347 lures you to the Epilogue: “Choices to be Made.”  It’s only 10 pages, and you read it as if it could save your political career.

Van der Kolk argues that childhood trauma, in the form of adverse childhood events, child abuse and neglect, “is the single most preventable cause of mental illness, the single most common cause of drug and alcohol abuse, and a significant contributor to leading causes of death such as diabetes, heart disease, cancer, stroke, and suicide.”  It’s a hefty book.  The author’s an academic clinician, has done some homework and some trenchwork.  Been at it for 30 years.  Tells a good story.  A Dutchman who reminds us that plenty of northern European countries have figured this out.  They provide better maternal and child care, universal health care at lower costs, and have lower crime rates with one tenth the incarceration costs we pay for in the US.

A pink sticky tab on p 167 draws you to a quote you write down for your next meeting with your advisers: “Economists have calculated that every dollar invested in high quality home visitation, day care and preschool programs [for high risk children] results in seven dollars of savings on welfare payments, health-care costs, substance abuse treatment, and incarceration, plus higher tax revenues due to better-paying jobs.”

You cancel both your appearances at ribbon-cutting ceremonies and spend your day scouring the book, making calls, unleashing your fact-checkers on the book’s major claims, and buying van der Kolk a ticket to Atlanta.  The next day your first question to your advisers is why childhood trauma is not on their short list.   They look at each other and then at you with that unmistakable message of polite condescension that reminds you that you are the newcomer in the room.  When you demand a translation, the epidemiologist to your right speaks up: “Sir, we’re bound to prioritize the high prevalence conditions.  Childhood trauma has not been operationalized as a diagnosis, beyond PTSD, which is a low prevalence condition in the general population, relative to our major players such as diabetes, obesity, heart disease.”

You pull out the book and turn to page 348 and say, “What do you make of this epidemiologic statement: ‘Since 2001 far more Americans have died at the hands of their partners or other family members than in the wars in Iraq and Afghanistan.  American women are twice as likely to suffer domestic violence as breast cancer….Firearms kill twice as many children as cancer does.’  Doesn’t that make trauma a high prevalence condition, whether they have PTSD or not?”

The room is quiet.  Is it the steamy heat or do they seem to be squirming?  Finally, the epidemiologist says, “The politics of childhood trauma are likely to be tricky, sir.” Then it dawns on you.  Everyone in the room is feeling what you’re feeling: shame.  This is an ugly topic.  And we don’t want to talk about it.  We ignore the evidence, even high-level experts ignore it, because it’s shameful what happens to “our kids.”    We ignore childhood trauma because we assume that it’s not a health condition that we can do something about.  But you remember when CDC elevated gun violence in the 1980’s to a public health condition that deserved prevention efforts.  Why not childhood trauma?

You ask who left this book on your desk; none of them claim the deed, though most of them are aware of the book. When you ask Mrs Deets, your portly administrative assistant and the sage of CDC for the past two decades, she smiles and says, “I heard you have a difficult choice to make, sir.  Now is there anything else that runs so deep in our culture?    That book came my way last year after I lost my grandson to heroin.”  It’s all there in her voice, a voice that sounds like Toni Morrison reading Beloved, the voice of women who grew up in the long shadow of slavery and domestic violence.  Looking at Mrs Deets, it’s hard to imagine how you could have missed this truth about what ails our country most.  It’s hard to believe that as recently as yesterday you wondered about the choice.

What if we allotted the same amount of resources to children with high childhood trauma exposures as we allot to children with other high-risk chronic conditions, such as cancer, cystic fibrosis, muscular dystrophy, or severe intellectual disabilities?  What if the high-risk children exposed to trauma were enrolled in programs that facilitated pre-school participation, case management through grade school and high school, tutors to reduce school dropout rates, family access to social workers and childcare and mental health services and vocational rehabilitation?    He said “budget neutral!”  So where would the money come from?  Department of Corrections, Medicaid, unemployment, DEA and ATF payrolls, police force payrolls.  For every dollar spent, seven dollars saved?  Get the economists to run the numbers.  The POTUS will need fresh numbers.

Then a smile ripples through you.  Maybe he already has the numbers.  Maybe he has read the book.

Trauma’s Toll on the Body

Imagine cruising down a highway at 65 mph some dark and rainy night until a pothole thumps your right tire, explodes it, whips you off the road, flips you—now you’re upside down skidding on the hood of your car, the squeal of metal on concrete or maybe on your skull piercing the night and your mind, for an eternity, until you smash into silence.   Later you wake in an ambulance, but no siren.  Nice people in jumpsuits tell you about your “minor laceration where your forehead knocked your steering wheel.”  Hours later the emergency room doc deems your survival a “seat-belt miracle,” and you take a cab home with just a band-aid above your eyebrow to show for your near-death experience with a pothole in the rain.   Will this experience mark the end of your life as a driver or just another bump in the road?

I’ve spent this past month reading and rereading and relishing Bessel van der Kolk’s book (2014) The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma.  This book fascinates me in ways that will fascinate anyone who has ever marveled at the power of traumatic memories to tyrannize an otherwise promising life.  How does trauma get such a grip on us and work its curse in such tormenting ways over so many years?  The surprising lesson here is embedded in his title: pay attention to the body.

Van der Kolk, a psychiatrist now in his early seventies, has given us the essence of his career devoted to plumbing the mysteries of psychological trauma, given it to us in a friendly voice that weaves clinical anecdotes and research pearls into a somewhat autobiographical narrative.  His book serves also as a history of the recent emergence of trauma psychology into popular culture and our diagnostic nomenclature.  I hear his voice more vividly for having worked with him for several years starting in 1982 at the Massachusetts Mental Health Center, where I was a resident and Bessel, about six years my senior, was starting his academic career as one of our psychopharmacology teachers.  Back then it was clear he was more passionate about the mysteries of trauma than the promises of pharmacology.

His title The Body Keeps the Score hints at the peculiar way we process traumatic memories when an event overwhelms us.   Instead of storing the memory along with the rest of our related events and associations that give it meaning and context, instead of reworking those memories over and over in the remembering and telling and retelling until we achieve a coherent narrative that helps us cope, other less adaptive memory processes can take over in the heat of the crisis.  During an adrenaline surge our frontal lobes can shut down temporarily, robbing us of judgment and the capacity to make complex decisions.  We shift into automatic mode and operate on reflex.   We flee or we brace for a fight.  Or we freeze when we’re helpless.  Some sensory processes operate on high alert while others shut down, so we end up with intense but fragmented memories.

After the experience we may be left with just a few pieces that make no coherent story.  Sequences are confused.  Sensations are recalled out of proportion to their meaning.  The intensity of the memories defies words, so it’s easy to avoid talking about it.  Without intending to, we may repress or “forget” large parts of the event.  The next time you watch Good Will Hunting [link] or read Toni Morrison’s Beloved [link], notice how the fragmentation and repression of traumatic memories drive the patchwork telling of the story.

Instead of being “metabolized” and stored as part of some coherent narrative like most memories, the traumatic memory is stored like a foreign body that forms an abscess around it.  The traumatic flashback fragment remains hot, retains the original intensity of feeling and content, lacks context.   Flashbacks repeat the threat and do not contribute to distancing or reworking the experience toward a sense of safety.

What toll does traumatic memory take on the body?  The toll varies with the trauma, the frequency of re-experiencing the trauma through flashbacks and nightmares, the duration of the re-experiencing, and the person’s innate vulnerability to stress.  Van der Kolk’s point is that no matter how much our conscious mind spares us awareness of the trauma through denial and repression and forgetting, the body and the unconscious mind keep the score.

Imagine the toll on a twelve-year old girl who has grown up with the threat of being raped by her stepfather for four years.  How fast does her heart beat when he walks in the door each evening?  How deep does she sleep each night?  What food or drink or drug or mental gymnastic can buffer her from her fear, her rage?  Long after the stepfather is removed, long after she has blanked out from memory large periods of her childhood, she may struggle to read her own alarm signals, to figure out whom she can trust.  The enemy is now within.  “After trauma the world is experienced with a different nervous system,” writes van der Kolk.  When you can’t tell whether you’re in a safe zone or a danger zone, you live on high alert, day and night.  Or you learn to discount all alarms.

People with post-traumatic stress disorder (PTSD) often live at the extremes of hyperarousal or numbness.  They feel either overcharged or emotionally dead, without much experience in the middle of the emotional spectrum where the rest of us live.  For them regulating affect often requires deliberate effort, much effort, sometimes seems impossible when the next highway pothole comes along.  That means they’re more likely to lose control of their behavior in costly ways, such as fighting, weeping, bingeing, drinking, racing, spending, road raging.  They’re more likely to develop chronic physical pain in concert with their anguish.  They’re more likely to develop heart disease at a young age, diabetes from overeating, and irritable bowel syndrome from a chronically inflamed gut.  Their capacity to dissociate as a way of coping with the helpless position of the victim makes them adept at ignoring internal signals of distress or dysregulation, such as denying chest pain or a lump in the breast.  Is it any wonder that several studies have found that PTSD predicts early death.

Eight of the 20 chapters in The Body Keeps the Score detail the “paths to recovery.”  The list of effective and promising new treatments for trauma is long and not what you would expect from a psychiatrist.  Van der Kolk is not impressed with psychiatry’s standard approaches to therapy and medications.  He writes, “Physical awareness is the first step in releasing the tyranny of the past.” (p. 101)  This means comprehensive treatment should begin with yoga or neurofeedback or massage therapy or body work or meditation or dance—some practice that helps the person tune in to internal signals about body states.

When your own physical sensations become the enemy, you have to learn to “befriend your body,” as van der Kolk calls it.  This process of relearning can be painful and slow, like learning to walk or talk again after a stroke, but trusting yourself is the first step toward trusting others.   The goal is the capacity to achieve a visceral sense of safety, which requires learning to control intense affects and endure exposure to triggers without hyperarousal.  This means retraining your body as you retrain your mind and brain.  Medications can pave the way at times, but the foundations of recovery from trauma are laid through therapy that fosters the reintegration of the mind, brain, and body at the deepest levels.  For many of us, that’s what it takes to prevent a near-death experience from tyrannizing the rest of our lives.