Tuesday, January 24, 2012

The Dissociation Capsule

The Dissociation Capsuleby Robert Scaer, M.D.

In my 30+ years of the practice of Neurology, I spent the last 20 as the medical director of a rehabilitation center, much of that
directing a multidisciplinary chronic pain program. We routinely treated the most challenging patients, those whose physicians
had basically given up their treatment in despair, and referred them to us. Our team included a full-time psychologist, and their
intake data revealed a dramatic incidence of child abuse (~60%) and of Borderline Personality Disorder (~30%) in our pain
clientele. Virtually all of them suffered from depression. Our frequent staff meetings often addressed how to avoid "splitting" of the
staff by our borderline patients.

Unlike many pain programs, we avoided the use of narcotics in these patients, and routinely involved drug detox in most. Our
patients often were admitted on huge doses of narcotics, but however high their dose, the pain was never relieved or even
substantially diminished. We found that detox from Oxycontin often was associated with more panic than with any symptoms of
narcotic withdrawal.

Mary was just such a patient. She'd had suffered a very traumatic injury, losing much of the skin of her left forearm in a roll-over
auto accident. Surgery and skin grafts saved the arm, but she was left with chronic, searing pain associated at the same time with
a feeling that the arm felt numb and detached as if it didn't belong to her. She also had a history of physical abuse as a child by her
father. Her admission photography showed a sad, distracted looking woman, with a strange, twisted posture. She stood with her
left shoulder markedly elevated, with her left arm rotated backward, her hand virtually behind her back, her head turned slightly to
the right. During meetings and exercise, her left hand often wandered off into strange, contracted postures of which she was quite
unaware. Although she was on over 80 mg. of oxycodone, her pain was unremitting, usually 10 on a 0-10 scale. Therapists
documented that she was forgetful, distracted, and often seemed to be in another world, but with dramatic mood swings, anger
and irritability. One could say that she was effectively detached from reality much of the time. One could also say that she typified
the majority of patients in my pain program.

What do you suppose Mary's diagnosis would be? Most of you would probably respond something like 307.89 Pain Disorder
Associated with Both Psychological Factors and a General Medical Condition. But the general medical condition was stable, and
for all intents, cured, and the psychological condition was complex to say the least. If one had asked Mary what she was feeling
during her distracted periods, she would have told you that at times she felt out of body, spacey and in "another place". Intrusive,
usually negative thoughts were running through her mind, some of which were almost delusional. During those times, despite
excruciating pain in her left arm, she had to look at it to find out where it was. Moving it was clumsy and uncertain. Mary clearly was
dissociated much of the time, and that dissociation also selectively affected her left arm.

Dissociation remains the bĂȘte noire of psychiatric diagnoses. It's features include "...a disruption in the usually integrated
functions of consciousness, memory, or perception of the environment" (DSM-IV, p. 477), but a unitary diagnosis continues to
evade us. We refer to states of depersonalization, derealization, distorted time and sensory perception, fugue states, amnesia and
dissociative identity disorder. Although conversion hysteria is accepted as a dissociative state, it has been relegated to the
category of Somatiform Disorders in the DSM-IV (DSM-IV, 1994). (Somatiform Disorders imply that a symptom is unexplainable on
the basis of any physical disruption of body function, and is therefore "psychological".) Opinions about dissociation range from its
dismissal as a valid condition or diagnosis, to its endorsement as the primary expression of traumatic stress.

But psychotherapy practitioners in the field know full well what dissociation is. It's that confused, distracted state in your patient that
prevents you from breaking through the fog into any semblance of meaningful contact. It's the patient "leaving the room", losing
contact with you when you've barely touched on the meaningful traumatic material, or when an obtuse reference to some
supposedly benign topic causes a short circuit to a traumatic cue in their memory. It's the state of confusion and distraction that the
patient describes, as if they've suffered a brain injury. It's the fortunately rare event where the patient "floods" during a session of
EMDR or exposure therapy, entering a state of unremitting panic, or becoming virtually regressed and unresponsive. Finally, it's
that state of detachment and inaccessibility they seem to live in that ultimately prevents any progress in therapy, regardless of
technique or therapist. I propose to take that clinical experience that you all recognize as dissociation and try to organize it into a
functional working model that not only will provide a single frame of reference for the diverse and hard-to-relate symptoms that it
seems to represent clinically, and to apply that model to an effective therapeutic paradigm. Unless we consider this divergent
group of clinical features that we call dissociation as part of a logical wholistic structure, we'll continue to struggle with dissociation
as a concept without a real definition.

(The DSM-IV defines dissociation as "a disruption in the usually integrated functions of consciousness, memory, identity or
perception of the environment". I would expand this definition (which basically says that dissociation is an apparently global
disruption in perception) to the concept that dissociation has its roots in the procedural memories for remote traumatic events, and
that the confusion between past and current events is the defining feature of dissociation. Current thinking would suggest that
when a patient is dissociated, they are experiencing distorted perceptions in a variety of possible areas - reality, time, memory,
sense of self, sense of the body, etc. In fact what they are experiencing are perceptions that have been stored in survival-based
procedural memory as if they reflect the experience of the present moment. The diagnosis of dissociation isn't even mentioned in
the DSM-IV description of Posttraumatic Stress Disorder (PTSD), the syndrome that defines the effects of exposure to a traumatic
experience. The primary diagnostic criteria for PTSD reflect that post-traumatic symptoms to a significant degree relate to
abnormal memory processes - dreams, flashbacks, intrusive thoughts and images, cue-related anxiety and startle, avoidance of
exposure to reminders of the trauma. Although the other important criteria for PTSD include arousal and avoidance criteria, one
could make the case that the entire symptom complex of PTSD is based on the premise that an event that occurred in the past is
perceived as a lived event that is still in the present. I'd like to make the case that trauma therefore could be defined as a corruption
of perception of time and of memory.

I need to take a little side trip and clarify what I mean by memory. We don't need to get into the complexities of memory theory to
understand its application to trauma. For our purposes, let's look at the differences between conscious (explicit) and unconscious
(implicit) memory processes. Explicit, or declarative memory, has many subtypes, but is basically what we use to remember facts
and events. It's what we use to memorize things to regurgitate for the test in the course we're taking, or in preparation for a
profession. Declarative memory is quite subject to rapid decay, and in fact to inaccuracy. Recall references to the inconsistency of
reports by witnesses at the scene of an accident, or how a story changes through multiple repetitions. I probably remember 20% at
best of what I memorized in medical school.

Our conscious experience of course is intimately associated with our autobiographical declarative memory of key events in our
lives - but in fact those events by definition were associated with significant emotional tone - deaths, births, celebrations, losses.
Memories associated with high emotional tone assume qualities of implicit, or unconscious memory - they are much more
hard-wired and permanent in nature. For example, think for a moment about your first images of the plane crashing into the Twin
Towers on 9/11. I'll bet that you can describe in detail the exact images of the room with the TV, what you had been doing before
that moment, and so on in great detail. These memories associated with high emotional tone become part of our personal
autobiography, and are retained in memory with the accuracy of implicit recall. Basically emotional memories have important
implications for survival.

But the most important of the subsets of implicit memory is procedural memory, a term that I will belabor you with throughout this
article. The primary function of procedural memory is the acquisition of information and skills that are necessary for survival. And
most of these have to do with the unconscious functioning of your body. It's how we learn skills and habits - the intentional
repetition of a sensorimotor process until it is automatic and unconscious, such as learning a musical instrument, a sport or an
art form. It's also how we learn to adapt to danger and threat - the negative associations that we unconsciously learn to avoid, and
the positive associations that we learn to seek. Survival-based procedural memory is based on classical conditioning - the pairing
of life experiences with threat or reward. Although some survival instincts are genetic - fear of falling, snakes and spiders - most
must be learned through experience - the spotted cat on the Kalahari Desert, the smell of gas in a home, the whine of an incoming
missile. Such memories are acquired in a flash, and stored for a lifetime. And such procedural memories, acquired and stored as
part of a traumatic experience and perceived not as skills, but as warnings of present danger, are also the essential ingredient for
all of the symptoms of trauma.

Returning to concepts of dissociation, disruption of perception of one's own identity is clearly a feature of dissociation, and the
noted neurologist, Antonio Damasio would maintain that one's identity, or sense of self, is in part based on one's somatosensory
awareness, the often subconscious perception of "feelings" of the body. In his book, Descarte's Error, he describes a compelling
working model of the self as: 1) "..representations of key events in an individual's autobiography (emotion-linked declarative
memory)...", and 2) "...the primordial representation of an individual's body." (Descarte's Error, p. 239) Our "autobiography"
basically consists of the sum total or our extrinsic and intrinsic memory for key events in our life that by definition are hard-wired
and intrinsic because of their emotional content. Memories such as weddings, births, deaths and athletic successes are
examples. Each one of these examples of key life events was associated with unique somatic and visceral experiences (the
tingling of the face in joy, the clenching of the gut in grief, the heart-pounding adrenaline rush of scoring the winning goal). These
sensations also form part of our "autobiography".

The second part of the self, our "body representation" is composed of all of the sensory information provided by the organs of the
body at any given present moment. For example, the sensations of emotions (feelings) at any given moment provide immediate
input to the brain regarding the emotional content of the moment, and how that should affect our immediate behavior. That input
will shape our behavior, cause that experience to be stored as a key event and continue to shape our evolving sense of self. So the
body itself plays an integral part in our evolving sense of self, both in past sensory memories and in those sensory experiences of
the present moment. The self may in essence be thought of as the embodied mind. Obviously, one's sense of self is an evolving
process. One could say that our sense of self evolves continuously with the passage of time though experiences of the present
moment superimposed on our past autobiographical memory.

Intense experiences, especially negative ones, will shape our sense of self dramatically, with the combination of images, sounds,
gut and somatic sensations that accompany them. These sensations become part of our body sense, and of our intrinsic
autobiography. Most victims of adult trauma complain that they no longer are the same person they were before the traumatic
event. They felt that their life was arrested at that point, was fragmented into disconnected pieces that they no longer could put
together as a whole. Because perception of the present moment is relegated to past traumatic experience in the trauma victim, the
evolving sense of self will also be "stuck" at that past moment in time. This process is in keeping with the well-known tendency for
the trauma victim's sense of self and developmental maturity to be relatively frozen at the time and age of the sentinel traumatic

Therapists in the brain injury rehabilitation program that I directed frequently commented that often the victim's sense of self was
probably the most damaged function they experienced. I came to realize that symptoms of diffuse cognitive impairment due to what
we called Minor Traumatic Brain Injury were often due to the fact that these patients were dissociated much of the time, and that
this state of perceptual confusion was the cause of their attention deficits, slow information processing and short term memory
impairment. In many of these cases, the velocity of the accident (5-10 MPH) was clearly not sufficient to cause a brain injury severe
enough to produces their degree of cognitive impairment. Not surprisingly, most of these patients whose symptoms included an
altered sense of self and significant cognitive impairment after an auto accident had a history of childhood trauma or family
dysfunction, since dissociation during childhood predicts the tendency to dissociate after trauma as an adult. So our sense of self
may be dramatically changed by a traumatic experience and the dissociation associated with it, especially if we arrive at that
traumatic event with a fragmentary sense of self based on a relatively dysfunctional childhood.

As we've said, the sense of self in significant part is shaped by perception of the intrinsic body sensations of the moment. Daniel
Stern describes the "present moment" as a brief period of time that lasts from 1-10 seconds and probably represents what we call
the "here and now", or even how we perhaps define consciousness. During this moment, we process sensory information coming
from both the internal sensations of the body, and from the external environment. The present moment is composed of Damasio's
"background feelings of the body", which contribute to our evolving sense of self. Perception of the present moment is tempered by
concepts of time (when is this happening?), intentionality (what, and what are we going to do about it) and vitality affects (shifting
emotions and their bodily feelings). For example, the present moment during a presentation to your boss might well consist of a
focused sense of now, a clear intention of facilitating a job promotion down the line, and mixed emotions of anxiety and excitement.
It might be associated with bodily feelings of cold, sweaty palms, tightness in the neck and jaws and "butterflies in the stomach",
or by the alertness and adrenaline rush of excitement. Working memory - short-term storage for processing the experience- also
contributes to our perception of the present moment. This fleeting period of awareness, constantly moving into the future, in a
sense defines what we perceive as consciousness. The present moment is essential for our ability to process information from
our internal and external world, and to act appropriately. During the present moment, we continue to develop our constantly
evolving sense of self. Impairment of perception of the present moment may be caused by intrusion oF old body-based procedural
memories, as well as key memories of past events, especially those linked to old trauma. For example, emotion-linked memories
of financial or marital conflicts may intrude on our thoughts as we go to the bedroom to get something, and make us forget why we
went there. The tightness in our neck triggered by the conflict may contribute to our distraction. The present moment has been
corrupted by the concurrent experience of feelings of past traumatic events, and the intention is lost.

We've noted that the uncorrupted present moment is associated with an appropriate concept of time (when?) based on input from
our prefrontal cortex. This is the dilemma of posttraumatic symptoms: internal and external cues of old traumatic memories
continue to trigger emotions and body sensations that don't represent the present moment, but rather past implicit memories
when the trauma was experienced. The present moment may be corrupted by these past traumatic autobiographical memories,
and the actual experience may be an illusion of time and perception. The somatosensory messages of the present moment that
contribute to our evolving sense of self are subordinated to old trauma-related body messages. For example, as we drive by the
scene of a recent MVA, our neck stiffens, we feel a little dizzy and for a moment forget where we're going. For a brief instant, we
would experience the emotion-linked memory of the accident itself. I would suggest that this unique narrowing, interruption and
corruption of perception of the present moment by past memory in traumatic stress is in fact what we define as dissociation.

Dissociation, almost by definition, is characterized by a unique and rather sharply defined state of altered perception that is
different from reality. As a state, we can assign it quite specific features, based on its unique alteration in various types of
perception, all of which are memories for past experiences. As a specific state, it will be defined by the boundaries of its content,
and I would therefore like to present the metaphorical, but quite functional definition of the dissociative capsule. The content of a
specific capsule will consist of procedural memories for the autonomic, somatosensory and emotional feelings of the trauma. All
of these states of course are associated with body sensations. Autonomic states (fight/flight/freeze) are associated with cardiac
and visceral feelings - pounding heart, cold hands, tremor, chest pressure, gut tightness and cramps. Emotions also are
associated with feelings such as the tingling rush of joy, the heavy sinking feeling of depression, the face-burning, constricting
feeling of shame. And somatosensory sensations (from the muscles, skin and skeleton) contribute to all of these feelings -
tightening of neck and back muscles, tingling of the skin, pressure in the head, even severe pain. Of course, this capsule would
also contain the very specific emotion-linked conscious memories of the event as well. And finally, since endorphins were
released in large amounts at the time of the threat and the freeze response that initiated the traumatic event, perceptions of the
dissociative capsule will often be distorted and bizarre.

The dissociative capsule would be quite specific to the traumatic event that defined it, and would consist of the sum total of all of
those procedural memories reflecting the experiences of the event that were stored, in their finest detail in a diverse grouped
cluster of perceptions. These diverse procedural memories, hard-wired and permanent, would be susceptible to recall in the face
of both internal and external environmental cues that reflect elements of the traumatic event. (Recall the MVA example noted
above.) That recall by definition would occur in the course of some present moment, and would be perceived as being present,
even though it reflected a past moment. It would interrupt the present moment for a variable period of time depending on the
intensity and specificity of the cues. It could last a few seconds, or in the case of numerous large capsules, could occupy one's
present moment most or all of the time. Emergence of the dissociative capsule into the present moment would destroy its function
(intentionality, acquisition of new memory and evolution of the sense of self). The present moment would consist of old
emotionally-based declarative memories and feelings from the body reflecting the autonomic, emotional and somatic input from
traumatic procedural memory. During this obliteration of the present moment, the person would exist in the past traumatic
experience, would respond to its messages as if confronted with the old trauma, and would be unable to form plans of action or
store new memories based on current experience. For that brief or prolonged period of time, consciousness and the mind would
be rendered inert. The victim would be frozen in a past traumatic moment, and their perception would reflect that moment. Finally,
the inevitable release of endorphins with emergence of the dissociative capsule would cloud cognition and perception, creating
the surreal state of dissociative perception.

The contents of a given capsule would be infinitely variable, as one can imagine. Let's use the analogy of experiencing an MVA to
illustrate the process. For example, a patient of mine was stopped at a light, when she heard the screech of brakes behind her.
She looked up into her rear view mirror, and saw a large truck as it slid into and impacted the rear of her car. She instinctively
reached back for her young child in a car seat in the rear, and then was thrown about within the restraints of her lap and shoulder
belt but essentially was uninjured. She subsequently experienced the typical symptoms of whiplash - neck and back pain,
dizziness with head movement, blurring of vision, ringing in her ears and problems with concentration and memory. She especially
note pain in her right shoulder and arm. These symptoms came and went, but particularly were brought on by any activities
involving being in a car.

When simply getting into her car, she noted pounding of her heart, tremulousness, neck tightness and pain, right shoulder pain,
lightheadedness and a sense of numbness and mild confusion. When stopped at a stoplight, driving by the scene of the accident,
hearing the screech of tires in the distance or hearing the crash of trashcans being loaded into a dump truck, all of these
symptoms returned proportionate to the intensity of the stimulus, occasionally associated with actual images of the truck in her
rear view mirror. They were also experienced with a surreal, detached quality. One would be tempted to attribute these symptoms
to the reexperiencing, arousal and numbing criteria for PTSD in the form of flashbacks. But the pain that she felt, the physical
sensation in her chest, the ringing in her ears and the dizziness were not imagined - they were actually felt as a physical
experience, and were exactly like the sensations she had experienced in the accident. During those experiences, she in effect was
living in the past, a time warp of the accident defined by its procedural memories.

The conscious emotionally-based memories of the images, sounds, smells and emotions associated with the accident also tend
to be distorted, exaggerated and intricately interwoven with their somatosensory components. The image of the grill of an
oncoming truck in posttraumatic memory may be bizarrely distorted, and huge, the sound of the crash like an exploding bomb, the
smell of the twisted metal choking in its intensity, the movements of the body like an epileptic seizure. Procedural memories of the
body would form a large component of the contents of the capsule, such as the reflex patterns of unconscious self-protective
muscle contractions throughout the body and the pain and movement-based sensory messages that accompanied them. The
stimulation of the balance centers of the brain and inner ears, the outward movements of the eyes in the face of threat, the
defensive clenching of the jaw muscles - all of these behaviors and sensory experiences would form a large component of the
cluster. The perceptions arising from these memories could include muscle bracing and spasm, jaw clenching, local pain,
numbness and tingling, violent movement, dizziness, deafening noise, disturbing images and blurred vision. Visceral sensations
linked to emotions and autonomic reflexes might include chest sensations of the pounding heart, and nausea and tightness in the

Autonomic phenomena invariably accompany trauma as part of the fight/flight/freeze response, and would play a prominent part of
the experiences of the MVA. These autonomic events and the physical sensations associated with them would actually be stored
in procedural memories, and triggered with related cues. Rapid heart-beat, soaring blood pressure, constriction of blood vessels
of the skin, dilatation of blood vessels of the heart and brain would form part of the precise procedural memory for traumatic
autonomic events. In the face of an associated freeze response, profound drop in blood pressure and pulse, with collapse and
weakness of muscles might form a separate memory cluster. One must recognize that in trauma, procedural memory even for the
most primitive of body processes occurs. These autonomic states would be replicated within the specific cluster when triggered by
cues from the traumatic event, just as in the clinical example above. One wouldn't just experience the sensations of the heart
pounding, the body would actually go through these autonomic changes when the cluster impinged on the present moment
triggered by a cue from the trauma such as another close call on the highway. One problem with trauma, of course, is that
traumatic cues may generalize (Pavlov called it irradiation) to less specific cues with the passage of time. Under these
circumstances, the cluster may be triggered by events that don't make much sense - the cues may become almost subliminal,
such as the color red if the other car was that color, or even nonspecific ambient life stress.

The emotional components of the traumatic event from the limbic brain will also be stored within the dissociative capsule. Fear,
terror, rage and emotional freeze may all be experienced in the MVA, and will be reflected in the exact form and specificity as in the
accident, such a rage or terror triggered by another close call. If the victim was also the cause of the MVA, shame may be
especially prominent.

At this point, you might object that what I've defined here is simply the component parts of what we call PTSD. I this model, we
define PTSD as a compilation of the varied procedural memories that define the dissociative capsule. In PTSD, reexperiencing
describes the emotionally linked (and therefore implicit) declarative memories of the capsule in the form of dreams, intrusive
thoughts, flashbacks and emotional distress. Avoidance describes the conditioned responses developed as a means of limiting
exposure to the environmental stimuli that might trigger the emergence of the capsule. Cognitive impairment, emotional
constriction, numbing and detachment probably in part reflect endorphinergic effects of the capsule. The sense of foreshortened
future uncannily reflects corruption of the present moment, a state of conscious perception necessary for moving into a conscious
future. The future is basically inconceivable in the absence of perception of the present moment. Finally, arousal in PTSD simply
reflects the emotional and autonomic content of the capsule, and their associated body sensations (feelings). Dissociation
therefore becomes the defining clinical state of trauma, with the symptoms of PTSD representing simple subsets of the capsule

Layered over these procedural memories is the pervasive effect on consciousness of endorphins, neurotransmitters that are
released in large amounts throughout the fight/flight/freeze experience and that cause analgesia, a state of blunted pain
perception, or numbing. Endorphins are released in any threat-based experience to diminish the need for ministration to an injury
that might inhibit successful attempts at flight or self-defense. They also mediate the freeze response so that analgesia can inhibit
movement patterns that might trigger further injury, since predators often attack only based on movement cues of the prey. And as
we've said, dissociation does have definite links to the freeze. Endorphins also contribute to the surreal perceptions of the
dissociative experience, such as feelings of detachment, unreality, out-of-body perceptions, confusion and distortion of body parts.
Procedural memory for these distorted dissociative perceptions is also just as precise as are somatic procedural, and
emotion-linked declarative memories. If perception was distorted as a result of endorphins at the time of the trauma, memories
within the capsule will be similarly distorted. But what about such limited and diverse traumatic experiences as the loss of a loved
one, financial destitution as a result of bankruptcy or an experience of profound shame? Such purely emotional events assume the
role of traumatic stress because they are associated with the loss of systems of social support structure that pose an intrinsic
threat to our existence. They are more than sufficient to trigger both fight/flight behavior, as well as the freeze. These experiences
consist of high levels of limbic and autonomic tone, and visceral body memories associated with those states - the chest and gut
clenching sensations of grief and hopelessness, the burning face and lightheaded feeling of shame and the chest tightening and
racing heart with the loss of ones livelihood. Being a captive or hostage would leave a capsule with similar autonomic and limbic
content, but with predominantly fear and terror and their typical autonomic visceral feelings. In other words, the dissociative
capsule may consist of any combination of its basic ingredients - procedural somatic, emotional and autonomic memories,
emotionally-based declarative memories and alterations of perception by endorphins. If a common life event such as those noted
above is sufficient to create a threat to one's means of coping, and helplessness is present based on the absence of options to
solve the problem, that event may assume the mantel of trauma, and its own dissociative capsule may be formed. The "size" or
intensity of the capsule would be dependent on the relative intensity of the experience itself, as in surviving a plane crash vs. just
seeing the plane fly into the towers vs. childhood incest. It may also be based on the repetitive nature of similar traumatic
experiences, as in child and spousal abuse. So repetitive sexual or physical child abuse as a child would be associated with a
capsule of great size, and highly intense and generalized cues based on the similar physical and emotional experiences within
each traumatic event, the number of exposures over time and its meaning within the child's social structure. The capsule
associated with shame, if repeated, could be sizeable, but might contain only autonomic, emotional and emotion-linked
declarative memories. The capsule related to a traumatic event that involved physical injury would contain all of the elements but a
predominance of procedural body-based memories, such as chronic pain. The reinforcement of common
autonomic/limbic/somatosensory traumatic events would create a capsule that occupies a large portion of ones autobiography of
key life events, and would therefore be more likely to interrupt the present moment frequently. The earlier in life that these traumatic
experiences have occurred, the more intense the effects and the greater the relative size of the capsule will be, with the same
harmful perceptual effects.

The quantitative impact of many life traumas, especially occurring in childhood, determines the amount of interference with
perception of the present moment that will occur in the trauma victim. When childhood trauma is severe, repetitive and varied,
posttraumatic dissociative perception would dominate most of their present moment, or consciousness. This condition could well
define such pervasive states of dissociation as Dissociative Identity Disorder (DID). It's generally recognized that DID is probably
based on complex traumatic childhood experiences, often associated with a mix of physical and sexual abuse. In this condition,
one would expect a variety of large, complex capsules, each with its own peculiar mix of procedural memory components.
Because each capsule would have its own unique autonomic procedural memory state, the various "alters" in DID would manifest
their own unique autonomic tone and physiology and even might manifest unique disease states. The autonomic nervous system
has a linear connection with the endocrine and immune systems, which are influenced by the pituitary gland through the
Hypothalamic/Pituitary/Adrenal axis (the HPA). Hypertension, diabetes, even immune disorders would be based on the specific
nature of the autonomic and endocrine abnormalities created by the specific autonomic procedural memory content of the
particular capsule.

Poorly understood complex medical syndromes, such as whiplash, could be viewed as dissociative capsules, the myofascial
neck and back pain, vertigo, labile blood pressure, temporomandibular joint syndrome, cognitive impairment and emotional lability
representing procedural memory for the myriad somatosensory, emotional, autonomic and cognitive experiences of the event. In
fact, many of the poorly understood medical syndromes such as chronic pain (especially headaches and low back pain), migraine,
fibromyalgia, chronic fatigue, irritable bowel syndrome and gastroesophageal reflux syndrome (GERDs) would represent the
procedural memory for somatic and autonomic states within capsules created by specific or cumulative traumatic events. It is well
known that these are syndromes that fluctuate markedly, especially in the face of life stress that may contain cues to the capsules.
If one accepts this premise, then many of the most common causes for visits to physician's offices in fact represent the somatic
symptoms generated by the autonomic and somatic procedural memories within cumulative dissociative capsules.

The concept of trauma as a sharply defined capsule of procedural memories for the events of the traumatic experience provides a
useful structure for building a comprehensive treatment rationale. Many accepted and validated therapeutic techniques in trauma
therapy are based on concepts of procedural memory, classical conditioning and extinction in trauma. Cognitive behavioral,
exposure techniques, and many therapies that employ imagery basically involve, at least in part, principles of extinction or
desensitization. There is plenty of evidence that these techniques are effective in diminishing the reexperiencing and arousal
symptoms of PTSD, but less so in reducing numbing and avoidance, symptoms that in part reflect the dissociative experiences in
trauma. I think this problem reflects the fact that the body-based procedural memories in trauma, those sensations that
accompany various autonomic, emotional and somatosensory states, form a large part of the trauma structure. If one accepts that
the somatic symptoms of so-called Somatization Disorder actually represent real and tangible experiences generated within the
dissociation capsule, then standard psychotherapy based primarily on verbal context addresses only a small part of the picture.
Words do not extinguish the posttraumatic messages of the body that we tend to ignore as part of the trauma structure. The good
news is that the incorporation of therapeutic techniques that access somatic procedural memories of trauma, and selectively
extinguishing these often neglected experiences and their symptoms adds a whole new dimension to the therapeutic mix.

The so-called somatically-based therapies for trauma introduce the incorporation of somatic procedural memory into the
therapeutic process. At this point, I think it's obvious that unless we specifically extinguish somatic cues within the dissociative
capsule, they will continue to emerge, trigger the dissociative state and interfere with perception of the present moment. The
persistence of somatization, dissociative symptoms, affect regulation and depression as late symptoms of trauma suggests that
the definition of PTSD is only the tip of the trauma iceberg. Unless one effectively extinguishes these somatic cues from procedural
memory, they will continue to intrude on consciousness and promote further sensitization, growth of dissociative capsules and
vulnerability to ambient minor trauma.

If one accepts the premise that extinction of somatic forms of traumatic procedural memory is an absolute prerequisite to healing -
(admitting that many do not) - then we need to address therapy from the standpoint of the unconscious, a state that defines implicit
forms of memory. We know that the limbic nucleus, the amygdala, evaluates the emotional content of incoming sensory stimuli
and triggers arousal if those stimuli imply threat. Antonio Damasio, in his book, The Feeling of What Happens, describes a
woman with bilateral injury to the amygdala. Although otherwise functionally normal, she showed no capacity for fear or rage.
Somehow we need to down-regulate or shut down the amygdala while the patient images, or otherwise accesses the somatic
sensations linked to the traumatic event. Without the amygdala "on-line" the somatic feelings of arousal will not occur, and implicit
procedural memories of the trauma - body sensations and emotionally linked declarative memories - will no longer have a
meaning of threat in the present moment of their perception. They will be relegated to past memory, a prerequisite to dissolution of
the dissociative capsule. Effectively down-regulating the amygdala in the face of experiencing the somatic perceptions of the
trauma should extinguish this conditioned association in relatively few trials. This process may explain the seemingly inexplicable
and sudden healing of traumatic memories seen in a number of the somatically based therapies, such as EMDR and EFT.

What therapy processes would down-regulate the amygdala?

Rituals, especially those associated with intense social interaction, are often part of the healing process in non-western and
especially indigenous societies, sometimes as part of the cultural norms, sometimes as practiced by tribal healers, or shaman.
They may involve repetitive behaviors such as drumming, dancing or singing, and frequently induce trance states that are hypnotic.
The use of hypnosis in treating trauma may have its roots in this process. Ritual may well play a role in the eye movements of
EMDR, the tapping of EFT and TFT and the repetitive affirmative statements of the latter two techniques. We know that brain
centers that participate in social and maternal-infant bonding - the orbitofrontal cortex and the limbic cingulate gyrus - also inhibit
and down-regulate the amygdala. It makes sense that social ritual would facilitate this process.

Integration of the cerebral hemispheres brings the left hemisphere online, a condition that is inhibited in arousal, where the left
frontal cortex and Broca's speech area seem to be selectively inhibited. Integration of the hemispheres would theoretically interfere
with and inhibit the independent function of the right amygdala. Cerebral hemispheric integration may be achieved through
alternating visual, tactile and auditory stimulation, and might down-regulate the right amygdala while the patient images the
traumatic event, removing the arousal charge. Bilateral hemispheric integration may be the desired effect in the alternating touch,
auditory and visual stimulation of EMDR. It also may occur with the eye rolling, counting (left hemisphere) and singing (right
hemisphere) employed in EFT. The reprocessing of traumatic memory attributed to EMDR might well be relegation of traumatic
memories to the past through extinction of their somatic components.

Empowerment is the ultimate goal of all trauma therapy - it removes the state of helplessness that is intrinsic to the trauma
experience. There are many ways to accomplish this, including replicating intentionally in a symbolic fashion the defensive
movement patterns that accompanied the traumatic event but were truncated by the freeze. This is accomplished unconsciously
through accessing the felt sense in Somatic Experiencing, and intentionally in a number of other somatic techniques, including
dance, balance, equestrian and art therapy. The ritualistic affirmative statements of EFT and TFT also may function as tools of
empowerment. Finally, providing a conscious cognitive structure for the meaning of the contents of the dissociative capsule after
its components have been extinguished empowers one with the knowledge that occasional recurrence of somatic symptoms
reflecting the capsule is actually an event from the past, and not once again part of an imminent threat.

These hypotheses are clearly speculative at best. Nevertheless, the field of trauma has yet to solve the dilemma of the cascade of
often-somatic posttraumatic symptoms that persist long after the criteria based symptoms of PTSD have subsided. The concept of
the dissociative capsule provides a wholistic model that reflects the content of the late posttraumatic experience, and begs for a
novel approach to its resolution through the use if techniques that address the feelings of the body. Although EMDR has achieved
recognition after years of exhaustive study, the esoteric nature of most of somatically-based techniques has relegated them to the
dustbin of accepted trauma therapy, despite their widespread use in many parts of the world, and the many uncontrolled studies
that reflect positive results. We may have at our disposal therapeutic techniques that ultimately promise the quality of healing
trauma that we have yet to achieve.


1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (1994).
Washington, D.C.:American Psychiatric Association
2. Damasio, A., Descarte's Error: Emotion, Reason and the Human Brain, New York:Avon Books, Inc., 1994
3. Stern, D., The Present Moment in Psychotherapy and Everyday Life, New York:W.W. Norton, 2004
4. Damasio, A., The Feeling of What Happens: Body and Emotion in the Making of Consciousness, New York:Harcourt Brace, 1996.

Monday, January 23, 2012

The Kindness of Children

The Kindness of ChildrenBRUCE D. PERRY, M.D., Ph.D. and MAYA SZALAVITZ
I watched them for a few moments before I walked into the waiting room. The boy’s behavior had an
innocent sweetness to it: I could see him smiling, crawling into his mother’s lap, squirming so that he
could sit face-to-face with her. Then, he tenderly reached his hand up to her mouth and touched her,
playful, exploring. The quiet interaction between the two was classic bonding behavior between a
mother and an infant, even a toddler. But Peter was seven. As I watched them, I could tell that mother
and child had frequently engaged in this gentle, soothing game. When I walked in I also noticed that
Amy, the mom, was embarrassed by it. Her husband, Jason, Peter’s father, seemed even more
ashamed when I appeared to have caught them.

“Sit up, Peter,” Jason said as he stood up and shook my hand. I walked over to the boy, stood over him,
looked down, and smiled, “Hi, Peter.” I put my hand out. Peter reached up to touch my hand. “Peter,
stand up and shake Dr. Perry’s hand,” Jason said. Amy tried to push Peter off her lap to his feet. Peter
went limp and laughed. It seemed like part of their game. “Peter, stand up,” Jason said again, his voice
patient but firm. I could feel his frustration and exhaustion. I knew they had their hands full. “That’s OK.
You guys get comfortable. I just wanted to see how you think things went today?”

I sat down across from them. “This first visit is really just to give Peter a chance to come and meet some
of us and start to get familiar with us. Hopefully, you had some fun today?” Peter nodded. “Use words,
honey,” Amy said. Peter sat up and said, “Yes.” The family had just spent three hours in our clinic for an
intake appointment. They had come to see us because Peter had a long history of speech and
language problems, as well as difficulties with attention and impulsivity. Not surprisingly, he also had
social and academic problems in school. Occasionally he had bizarre and ferocious outbursts in which
he seemed to completely lose control. They were terrifying and, unlike ordinary temper tantrums, could
last for hours. Peter’s parents had adopted him from a Russian orphanage when he was three years
old. They had immediately fallen in love with the blonde, blue-eyed boy with rosy cheeks who looked like
a little angel. The operators of the orphanage had proudly shown off how well fed he was and how clean
their facility was but, in truth, Peter and the other children who lived there had been profoundly neglected.

Amy and Jason had heard about our work with maltreated children from other adoptive parents. We
were at the end of the first day of a two-day consultation visit at our clinic. The family had traveled over
five hundred miles for the evaluation. “So, Peter, will you come back and visit us tomorrow?” I asked.
“Yes,” he said with a big smile. Our clinicians had a lot of work to do before then. During a typical
evaluation, our interdisciplinary group of psychologists, social workers, child psychiatry fellows, and
child psychiatrists usually spread multiple visits out over a few weeks to get to know a child and his
family. In Peter’s case the process was condensed because he lived so far away. Records from the
schools, the child’s pediatrician, previous mental health providers and other professionals were
available for review to process and integrate into our impressions of the child and family. We also did a
brain scan, an MRI, as part of a study we were working on to see how early neglect affected the brain.
The data from our research has shown that significant early life neglect such as that seen in formerly in-
stitutionalized children like Peter leads to smaller brain size over all, brain shrinkage in certain regions,
and a host of brain-related functional problems. By finding which areas were most affected in Peter’s
case, we hoped to target our treatments to maximal effect. During the evaluation period, sometimes as
many as a dozen staff members would meet to talk about what we were seeing and experiencing with
this child. It was a process designed to identify the child’s strengths and vulnerabilities, and carefully
determine his current developmental stage in a host of domains from perceptual abilities to motor skills,
from emotional, cognitive and behavioral abilities to moral sentiments. This enabled us to come to a
preliminary diagnosis and make our initial recommendations for intervention. Although it would be too
time consuming and expensive to replicate in many settings, we hoped to develop models of care
based on this process that would be less staff intensive.

At the time we began working with Peter and his family, we’d made good progress on our
neurosequential approach to maltreated children. We’d recognized that victims of early trauma and
neglect need experiences such as rocking and being held appropriate for the age at which they’d
suffered damage or deprivation, not for their chronological age. We’d found that these develop-mentally
appropriate enrichment and therapeutic experiences had to be provided repeatedly and consistently in
a respectful and caring manner. Coercive, punitive and forceful delivery only made things worse. We’d
also started to incorporate music, dance and massage in order to stimulate and organize the lower
brain regions, which contain the key regulatory neurotransmitter systems involved in the stress
response. As we’ve seen, these areas are more likely to be affected by early trauma because they
undergo important, fast-paced development early in life. Finally, we’d begun to use medications to help
children with troublesome dissociative or hyper-arousal symptoms.

But while we had realized that ongoing relationships are critical to healing, we hadn’t yet fully
understood how important peer relationships are, especially as children get older. The details of Peters
past brought the critical role of relationships into vivid focus for me. Peter had been raised without adult
attention for the first three years of his life. He’d been kept in what was basically a baby warehouse: a
big, bright room with sixty infants in seemingly endless, straight rows of perfectly sanitized cribs. The
two caretakers on duty for each shift would work methodically from one bed to the next, feeding each
child, changing his or her diaper, then moving on. That was all the individual adult attention the babies
received: roughly fifteen minutes each per eight-hour shift. The infants were rarely spoken to or held
other than during these brief intervals; they were not rocked or cradled or cooed at because there
simply wasn’t time for staff to do more than feed and change, feed and change. Even the toddlers spent
their days and nights caged in their cribs. With no one but each other to turn to, the children would reach
their tiny hands through the bars into the next crib, holding hands, babbling and playing patty-cake. In the
absence of adults, they became parents to each other. Their interaction, as impoverished as it was,
probably helped to mitigate some of the damage such severe deprivation can cause.

When Peter’s adoptive parents first brought him home, they discovered that he was trying to
communicate with them. Delighted, they sought a Russian translator. But the Russian translator said his
speech wasn’t Russian; perhaps the orphanage workers had been immigrants from elsewhere in
Eastern Europe who had taught the children to speak their native tongue? A Czech speaker said it
wasn’t Czech, however, and soon Amy and Jason learned that Peter wasn’t speaking Hungarian or
Polish, either. To their surprise, they found that the words Peter spoke didn’t belong to any known
language. Apparently, the orphans had developed their own rudimentary language, like the private
speech of twins or the improvised signing of deaf children raised together. Like King Psamtik of Egypt,
who, according to Herodotus, isolated two children to learn what language they would naturally speak
without the opportunity to learn from people around them, the operators of the orphanage had created a
harsh and accidental experiment in linguistics. On their own, the children had apparently created and
agreed upon several dozen words. One word the translators were able to figure out was that Mum
meant adult or caregiver, just as similar sounds mean mother in almost every known human language,
since the mm sound is the first one babies learn to make while suckling.

In our clinical meeting, my team and I went over everything we knew about the boy’s early history;
including his limited exposure to adults and his linguistic deprivation. We also discussed his adoptive
parents. My initial impression of Amy and Jason was confirmed by the rest of the staff: everyone agreed
that they were remarkable. Even before they’d adopted Peter, they had read parenting books, watched
parenting videos and talked extensively with their pediatrician about what to expect when adopting a
child like him. After they brought Peter home they worked with speech and language therapists,
occupational therapists, physical therapists and mental health providers to help Peter catch up. They
followed the advice they were given diligently. They spent money, time and energy trying to give Peter
what he needed to grow up healthy, happy, productive and compassionate. Yet, despite all of their best
efforts, and the efforts of the dozens of specialists, Peter continued to struggle. He had improved
dramatically in many regards, but his progress was spotty, slow and incremental. He would learn new
skills only after hundreds of repetitions, not dozens like other children. He learned English but his
enunciation was strange and his grammar was mangled. His movements were also uncoordinated, and
even when he tried to sit still, he would sway. Also, he would rarely establish or maintain eye contact
appropriately. At seven, he still had several primitive self-soothing behaviors, primarily rocking and
sucking his thumb. He would sniff extensively at everything that he ate before putting it into his mouth
and also tried noticeably to catch the scent of people whenever he met them. He was easily distracted
and often laughed and smiled to himself, giving the impression that he was in his own little world. And in
the last year he seemed to have hit a developmental plateau, and perhaps even regressed a bit.
We first discussed Peter’s strengths, starting with his friendly, almost goofy manner. He was also well
above average in some aspects of language and seemed to have some mathematical talents. He was
extremely nurturing, but in a blatantly immature fashion, responding to peers and adults the way a
toddler might. It became clear through our discussions that while Peter was in some ways cognitively
seven, in other domains, he acted much younger. Confirming our observations regarding the use-
dependent nature of brain-development, the areas where he was doing better were related to brain
regions that had received stimulation, and those where he had deficits represented brain regions that
had either been more severely deprived or had not yet received enough stimulation to make up for the
earlier neglect. The scans of his brain reinforced our observations of his fractured neurodevelopment:
he had cortical atrophy, large ventricles (which meant that spinal fluid was taking up space that would
normally have been occupied by brain tissue) and lower-brain structures that were small for his age and
likely underdeveloped. Such splintered development is common in children who grow up in chaotic or
neglectful environments. It causes tremendous confusion for parents, teachers and peers. From the
outside, Peter looked like a seven-year-old boy, but in some ways he was only a three-year-old. In
terms of other skills and capabilities, he was eighteen months old, and he was eight or nine years old in
still other respects. This inconsistency was a major source of the family’s problems.

There were also important differences in the way each parent interacted with Peter. When he was home
and alone with Amy, she was extremely attuned to his needs. If he acted like a baby, she would engage
him at that age level, and if he acted like an older child, she would interact with him that way. I believe
that her intuitive capacity to meet his developmental needs was the primary reason he had made as
much progress as he had. But as Peter got older Jason began to question some of Amy’s babying of
the boy. This caused tension in the marriage, with Jason arguing that Amy was responsible for Peter’s
lack of progress because she was smothering him, while Amy insisted that he needed the extra
affection because of his past. Such differences are an almost universal feature of parenting. However,
when disagreements are profound as they were becoming in Amy and Jason’s case, they can lead to
serious marital problems. I had seen the conflict in my brief interaction with the family in the waiting
room. Part of my job would be to help the couple understand Peter’s needs and explain to them how it
was necessary to meet him where he was developmentally. That way, they would be able to learn to
avoid overwhelming Peter and frustrating themselves by requiring age-appropriate behavior in a
domain for which he did not yet have the capacity.

When the family came in for the second day of the evaluation we gave Peter some formal psychological
tests. Later we observed more parent/child interactions and sent the boy off for another play break.
Finally, it was time to tell the parents what we thought about Peter’s case and what we proposed to do
to help him. I could see that Amy and Jason were anxious as soon as I walked into the room. “What do
you think?” Jason said, clearly wanting to get bad news out of the way. “I think Peter is really a very lucky
boy,”I began, “You are wonderful parents. And he has shown remarkable progress over the last four
years.” I paused for a moment to let that sink in. Then, I added, “Your efforts are heroic. You must be
exhausted?” Amy started to cry. Her husband tenderly put his arm around her, and I got some tissue
and handed it to her. She wiped her eyes. I began to tell them what I thought, asking them to interrupt if I
said anything that they thought wasn’t accurate or didn’t make sense. I related Peter’s history as I
understood it, recounting the details of the orphanage and the list of developmental delays he had
experienced. Then I asked if I was right in suspecting that when Peter became upset all of his
developmental progress would seem to disappear and he would act in primitive, almost frightening
ways. Perhaps he’d lie on the floor in the fetal position, moaning and rocking, or perhaps he’d let out
unearthly screams. I added that I thought that once he started to get stirred up or overwhelmed he
probably reached a point of no return and that he seemed to regress before slowly coming back to
himself. They nodded. That’s when I explained how changes in our emotional state can affect how we
learn. Skills that we’ve mastered like comprehension of certain concepts or even use of language itself
may dissipate when we get worked up. I talked about how new or frightening situations would be
stressful to a child like Peter and would likely prompt this kind of regression. Wrapping up what we’d
learned from the evaluation, I said, “So, I think we have a pretty good idea about Peter’s problems and
how he ended up with them. We also know some of his strengths; not all, but some. The key now is
whether we can use what we know to help him.”

I paused, struggling to strike a balance between hope and caution. “Let me take a moment and talk with
you about how the brain develops,” I began, “I think if you understand this a little bit more you will feel
better about the progress that Peter has made, and I think you will better understand why progress now
seems so slow?” As I spoke, my thoughts about the theory and practice I’d been working on for so
many years seemed to crystallize for the first time as a coherent whole. I drew several charts on a blank
piece of paper. The first showed a simple comparison of the growth of the brain relative to the growth of
the rest of the body, making the point that while the body doesn’t reach its adult height and weight until
adolescence, the brain’s growth follows a much different path. By age three it has reached 85 percent
of its full adult size. The human brain grows most rapidly early in life, I explained. In fact, the majority of
brain growth takes place in the first three years of life. I wanted to help them understand the full
significance of the fact that Peter had been in a sterile, neglectful institution during that critical period
when the brain is rapidly organizing itself. Then I drew a pyramid and turned the page upside down. The
brain is organized from the bottom to the top, I said. The top part here, I noted as I pointed to the wide
base of the upside-down pyramid, is the cortex, the most complex part of the brain, responsible for our
ability to think and for integrating many of our functions. I also described how some of the lower regions
work, how the central emotional areas allow us to make social connections and control our stress and
how the core brainstem areas drive the stress response itself. I explained how these regions awaken
sequentially during development, starting from the innermost brainstem and moving out toward the
cortex as the child grows.

I discussed how the development of higher, more complex brain regions relies on proper organization
of the lower, simpler areas. I explained how deprivation could affect these regions and cause the wide
variations in their son’s behavior. “The key is to parent Peter where he is developmentally, not where he
is chronologically,” I said. Jason nodded, beginning to understand what I was saying. “Which is a very
difficult thing to do, right?” Now, both parents nodded. “The challenge is that, in one moment, you will
need to have expectations and provide experiences that are appropriate for a five-year-old, for
example, when you are teaching him a specific cognitive concept. Ten minutes later, however, the
expectation and challenges will have to match those for a younger child, for example, when you are
trying to teach him to interact socially. He is, developmentally, a moving target. This is why parenting
these children is such a frustrating experience. One moment you are doing the correct thing and the
next, you are out of sync.” Amy and Jason had experienced this dichotomy many times, but until this
conversation they hadn’t been able to articulate it. My explanations helped them enormously,
immediately reducing their conflict over babying Peter and helping Jason not worry when his wife
engaged in it. Now, in fact, he could allow himself to do it as well. Amy, however, could also see from
what we’d taught her that there were times when Jason’s more demanding parenting style would be

But explanations alone would not be enough. The core challenges of parenting Peter would remain the
same and it would be close to impossible for either parent to be attuned to him always or even most of
the time without more support. Both parents were spent, emotionally and physically. We would need to
help them get some respite care. We suggested bolstering their social network, taking time for
themselves as a couple and doing things they enjoyed so that they could recharge their batteries for
their time with Peter. Amy and Jason were open to all of our suggestions. Since they did not live near
our clinic, we had to work with and through their local providers. Fortunately, most of the pieces of a
good clinical team were in place. Peter had an excellent speech therapist, occupational therapist,
master’s level therapist and an understanding pediatrician. We had talked with all of them. We wanted
to add therapeutic massage and a music and movement class to his routine, which had been useful for
other children who suffered early neglect.

But what I thought, at first, would be just another piece of the puzzle turned out to be the most important
element: Peter’s school and, especially, his classmates. As I looked over his history, I suddenly
recognized that most of Peter’s progress had come in the first three years after he came to the United
States: when he spent his time alone with his parents, or with adults, or one or two peers selected by
them. When he began attending kindergarten, however, his progress had ceased and his behavior
problems had intensified. His mother had intuitively understood that he was chronologically six but
behaviorally two, but his classmates couldn’t comprehend why he behaved so strangely. Even his
teacher didn’t know how to handle him, despite having been told of his background. Peter would grab
toys from other children without asking, missing the social cues the other kindergartners understood
about when it was OK to take something and when it wasn’t. He didn’t understand when he should
share his things and when to keep them to himself, when he should speak and when he should be quiet.
At circle time he’d suddenly get up and slip into the teacher’s lap or begin to wander around without
realizing he wasn’t supposed to. And he’d sometimes shriek and have his terrifying tantrums. As a
result the other children began to fear and marginalize him. His oddly accented English didn’t help. His
classmates viewed him as a strange and frightening boy.

He’d done well in the sheltered world of his adoptive home, with one-on-one relationships with adults
who knew and loved him. But the complex social world of kindergarten, with its varying peer and
teacher relationships to negotiate, was beyond him. Instead of the patient, nurturing, loving responses
he got at home, at kindergarten his behavior was met with suspicion and, often, outright rejection. The
classroom filled with noisy children and loud toys and frequent movement was overwhelming to him.
Where once he understood what was expected of him and was treated gently if he wasn’t able to do it,
now he couldn’t figure out what was going on. No matter how many hours of healthy positive
experiences Peter had each week, the hours when he was marginalized or teased could easily
overshadow them. Peter had no real friends and preferred to play with much younger children; he felt
most comfortable with three- or four-year-olds. His own classmates didn’t know what to make of the boy
who talked funny and often acted like a baby. In many situations children can be kind and nurturing to
someone who appears to be younger and more vulnerable. But Peter frightened them. The behavior of
his classmates was predictable.

What was happening in this classroom was a small version of what happens all across the planet in
various forms every day. Human beings fear what they don’t understand. The unknown scares us. When
we meet people who look or act in unfamiliar or strange ways, our initial response is to keep them at
arm’s length. At times we make ourselves feel superior, smarter or more competent by dehumanizing
or degrading those who are different. The roots of so many of our species’ ugliest behaviors - racism,
ageism, misogyny, anti-Semitism, to name just a few - are in this basic brain-mediated response to
perceived threat. We tend to fear what we do not understand, and fear can so easily twist into hate or
even violence because it can suppress the rational parts of our brain.

Faced with Peter’s growing ostracism and social rejection, Amy and Jason wanted to know what to do:
should they hold him back in kindergarten, hoping he’d learn more socially the second time around? Yet
his cognitive abilities were clearly on grade level for first grade, perhaps higher. Peter was intellectually
advanced, but socially clueless. I realized that if he was going to catch up, he was going to need the
help of his peers. It seemed to me that we might as well try letting him start first grade. When I had
worked with adolescents, some of them had allowed me to talk with their classmates about their
traumatic experiences and the effect it had on their brain. A bit of understanding had gone a long way in
helping improve their social lives. But could this work with first graders? And would Peter find it

I knew that I would be in his hometown several weeks after his evaluation and could talk to his
classmates at that time. I went back to explore this possibility with Peter. As we were coloring, I asked,
“Peter, do you remember living in Russia?” He stopped and looked at me for a moment. I kept slowly
coloring, not looking back at him. The pace of his coloring slowed. I was just about to ask again when
he took a new sheet of paper and drew a big blue circle around the entire page.” This is Russia?” He
held the page up to me. He placed the paper back on the floor, took a color and made one tiny,
delicate, almost invisible dot. “And this is Peter.” I looked at him; he was clearly sad. He was eloquently
expressing how he felt at the orphanage, where he’d been special to no one, just one of dozens of
anonymous babies. I smiled sympathetically at him, then raised my eyebrows and said, “But that isn’t
Peter anymore, is it?” He shook his head no, and smiled back. “ Peter, I was thinking that I would come
to your first grade class to visit.” I wasn’t sure he would understand, but I wanted him to know what I
wanted to do and why. “OK? You know how we have talked about how your brain is growing and
changing? I was wondering if you would mind if I talked to your class about the brain. And maybe a little
about the way you lived before you came to live with your parents?” “OK,” he said, thoughtfully, adding,
“Will you bring the pictures?” “Which pictures?” “The pictures of my brain?” “ Sure. You won’t mind if I
show pictures of your brain to your class?” “No. My brain is cool.” “You know, Peter, you are so right.
Your brain is cool?”

And so, with his permission and with that of his parents and his school, I decided to see if I could make
first graders into a new community of therapists for Peter.  I addressed his first grade class at the
beginning of the school year. “I’m Peter’s friend,” I said. I study the brain and Peter asked me to come
from Houston to tell you some of the things about the brain that I taught him. I had Peter come up to the
front of the class and serve as my assistant. I told the first graders about the brain, and about how in
some ways, it acts like a muscle. I talked about how they were exercising their ABC muscles in school
and about the importance of repetition. I described how they had many other similar kinds of muscles in
their brains that also needed certain kinds of attention in order to grow big and strong. I talked about
how the brain develops and what makes everyone’s brain work, emphasizing how the brain changes.
“Remember, Peter, when we were talking about how it takes a lot of practice to learn anything new?
That is because the brain changes when you use it, use it, use it.” I looked at the children and then back
at Peter, “Right, Peter?” He smiled and nodded. “And that is why your teacher keeps having you
practice writing again and again; and practice your letters again and again and again.” I showed some
slides; I brought a model of the brain and Peter passed it around. I answered questions. “What part of
the brain makes you talk? What color is the brain? Does the brain keep videos of your life?” I told the
children how important it was for a developing baby’s brain to get stimulation from talk and touch and
human interactions. I told them the same things that I told parents, judges, pediatricians and my own
staff just with fewer big words.

Then I talked a little bit about how different children grow up in different homes. How Japanese children
learn Japanese; how in some cultures mothers carry their babies around all day long during their first
year of life. How some children don’t get as much touch or talk or love early in life, and how that can
change the brain. They were having fun. We laughed. Peter was smiling. Then, it was time. I didn’t know
how much I would say, or even what I would say. I would let the response of the children and Peter guide
me. I jumped in, “Well. Thank you for letting me come to your classroom. Peter told me about you guys
when he came to visit me in Houston. I know he went to kindergarten with many of you.” A few of the
children raised their hands.

“We asked Peter to come to our clinic in Houston because we wanted to learn from him about his
amazing brain.” The children looked at Peter. ”See, when he was a little boy he spent every minute of
every day for the first three years of his life in one crib.” The children looked interested, but kind of
confused. “Peter was born in another country where they did not know very much about the brain. His
parents could not take care of him, so Peter went to an orphanage when he was just a baby. In this
orphanage each baby was put in a crib and that was their home. They didn’t get to wander around,
crawl anywhere, or even practice standing so they could learn to walk. Until his parents came to get him
when he was three, Peter never had a chance to walk around, to play with friends, to get a hug from any
loving grown-ups. His brain didn’t get very much stimulation.”

The room was completely silent: twenty-six six-year-old children didn’t move, speak or fidget. “And then
when he was three, his new parents came and brought him to live in Tulsa.” I paused to let some of the
tension dissipate. “And that is when Peter’s amazing brain started to learn so many things. Even though
he had never heard English, he learned English in just a couple years. He had never had a chance to
walk or run or skip and he learned to do all of those things.” Peter looked embarrassed. I didn’t want to
push too much. “And so even today, Peter’s amazing brain is learning. He has really done great. And
that is why we wanted to meet Peter and learn more about how any person with such a hard start in life
could do so well?” Then I ended with, “Part of what we learned is that every day in school, Peter learns
things from all of you. He watches how you do things, he learns from playing with each of you and he
learns from just being your friend. So thank you for helping Peter. And thanks for letting me come and
talk about the brain.” It was a short and simple talk. I tried to take an unknown – Peter -  and make him
less frightening to these children. And over time, their natural goodness emerged. No longer an odd
and scary boy, Peter became popular - so popular, in fact, that his peers would argue over who got to
sit next to him, who got to be his partner, who got to be in his group. The brightest and strongest
children in his class took a special interest in him and their leadership made all the difference. They
included him, protected him and, ultimately, provided therapeutic experiences that helped Peter catch
up. They were tolerant of his developmental problems, patient in correcting his social mistakes, and
nurturing in their interactions. These children provided many more positive therapeutic experiences than
we ever could have given Peter.

Children, just like us adults, react badly to the unknown, to the strange and unfamiliar, especially when
they themselves are trying to adjust to a new situation like the start of a school year. Although their
social hierarchies aren’t always so easy to influence, most bullying and social rejection begins with fear
of the unfamiliar, and adults have much more influence over the process than they may believe. When
children understand why someone behaves oddly, they give him or her more slack, generally. And the
younger the children are, the more easily they are influenced by both obvious and subtle cues of
rejection and acceptance from adults. These cues often set the tone for the children’s status systems,
and teachers and parents can either minimize bullying or unfortunately, maximize it, by either strongly
discouraging or tolerating the scapegoating of those who are different. Knowing that Peter’s immature
behavior came from his history of deprivation helped his classmates reinterpret it. When he grabbed
something or talked out of turn, they no longer saw it as a personal affront or jarring oddity, but simply as
a remnant from his past that they’d been taught to expect.

The results were rapid: almost immediately he stopped having tantrums and outbursts, probably
because what had prompted them was frustration, a sense of rejection and feeling misunderstood.
Because the other children were more forgiving and more explicit about the social cues they were
giving him, he was able to read them better and thus able to fit in better. What had been a downward
spiral of rejection, confusion and frustration became instead a cascade of positive reinforcement, which
fed on itself. The huge gaps in developmental age across emotional, social, motor and cognitive
domains slowly filled in. By the time Peter reached high school he no longer stood out and he has
continued to do well, both academically and socially. His peers and his family healed him by creating a
rich social world, a nurturing community. While the neurosequential approach helped us provide the
specific stimuli his brain had lacked, massage offering the physical affection that he’d missed, and
music and movement to help restore his brain and bodily rhythms, none of that would have been enough
without Amy and Jason’s love and sensitivity and without the patience and support of his classmates.
The more healthy relationships a child has, the more likely he will be to recover from trauma and thrive.
Relationships are the agents of change and the most powerful therapy is human love.
The Who Boy Was Raised as a DogAnd Other Stories from a Child Psychiatrist’s Notebook
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