PLEASE all of attachments... Because its a long paper, you still have the BOOK as well.

-( THE BODY KEEPS THE SCORE BRAIN, MIND,ANDBODY I NTH EHEA LI NG 0F TR AUM A Bessel A.van derKolk, M.D.

~ Penguin Books 264 THE BODY KEEPS THESCORE had happened along time ago.Asone ofmy patients said,making adismis- sive hand gesture: "It'sover." While wedon't yetknow precisely howEMDRworks, thesame istrue of Prozac. Prozachasaneffect onserotonin, butwhether itslevels goup or down, andinwhich braincells,andwhy thatmakes people feelless, afraid, is still unclear. Welikewise don'tknow precisely whytalking toatrusted friend gives suchprofound relief,andIam surprised howfewpeople seemeager to explore thatquestion." Clinicians haveonlyoneobligation:to dowhatever theycantohelp their patients getbetter. Because ofthis, clinical practice hasalways beenahotbed for experimentation. Someexperiments fail,some succeed, andsome, like EMDR, dialectical behaviortherapy,andinternal familysystems therapy, go on tochange theway therapy ispracticed. Validating allthese treatments takes decades andishampered bythe fact that research supportgenerally goes tomethods thathave already beenproven towork. Iam much com- forted byconsidering thehistory ofpenicillin: Almostfourdecades passed between thediscovery ofits antibiotic properties byAlexander Flemingin 1928 andthefinal eiucidation ofits mechanisms in1965.

Oil CHAPTER 16 LEARNIN.G TOINHABIT YOUR BODY: YOGA As we begin tore-experience avisceral reconnection withtheneeds of our bodies, thereisabrand newcapacity towarmly lovetheself.

We experience anew quality ofauthenticity inour caring, whichredi- rects ourattention toour health, ourdiets, ourenergy, ourtime man- agement. Thisenhanced careforthe self arises spontaneously and naturally, notasaresponse toa"should." Weareable toexperience an immediate andintrinsic pleasure inself-care.

-Stephen Cope, YogaandtheQuest forthe True Self T he firsttime Isaw Annie shewas slumped overinachair inmy waiting room, wearing fadedjeans andapurple Jimmy CliffT-shirt. Herlegs were visibly shaking, andshekept staring atthe floor evenafterIinvited her in. Ihad very little information abouther,other thanthatshewas forty-seven years oldand taught special-needs children.Herbody communicated clearly that shewas tooterrified toengage inconversation-or eventoprovide rou- tine information aboutheraddr~ss orinsurance plan.People whoarethis scared can'tthink straight, andanydemand toperform willonly make them shut down further. Ifyou insist, they'll runaway andyou'll neverseethem again.

Annie shuffled intomyoffice andremained standing,barelybreathing, looking likeafrozen bird.Iknew wecouldn't doanything untillcouldhelp her quiet down. Moving towithin sixfeet ofher and making sureshehad r···· t '!K 266 :rHE BODY KEEPS THESCORE unobstructed accesstothe door, Iencouraged hertotake slightly deeper breaths. Ibreathed withherand asked hertofollow myexample, gentlyrais- ing my arms frommysides asshe inhaled andlowering themasIexhaled, a qigong technique thatoneofmy Chinese students hadtaught me.She stealthily followedmymovements, hereyes stillfix~d onthe floor. Wespent about halfanhour thisway. From timetotime Iquietly askedhertonotice how herfeet feltagainst thefloor andhow herchest expanded andcon- tracted witheach.breath. Herbreath gradually becamesloweranddeeper, her face softened, herspine straightened abit, and hereyes lifted toabout the level ofmy Adam's apple.Ibegan tosense theperson behind thatoverwhelm- ing terror. Finally shelooked morerelaxed andshowed methe glimmer ofa smile, arecognition thatweboth were inthe room. Isuggested thatwestop there fornow-I'd madeenough demands onher-and askedwhether she would liketocome backaweek later.Shenodded andmuttered, "Yousure are weird." As Igot toknow Annie, Iinferred fromthenotes shewrote andthe drawings shegave methat shehad been dreadfully abusedbyboth herfather and hermother asavery young child.Thefullstory wasonly gradually revealed, asshe slowly learned tocall upsome ofthe things thathadhap- pened toher without herbody being hijacked intouncontrollable anxiety.

I learned thatAnnie wasextraordinarily skilledandcaring inher work with special-needs kids.(Itried outquite afew ofthe techniques shetold me about withthechildren inour own clinic andfound themextremely helpful). Shewould talkfreely about thechildren shetaught butwould clam up immediately ifwe verged onher relationships withadults. Iknew shewas married, butshebarely mentioned herhusband. Sheoften coped withdis- agreements andconfrontations bymaking hermind disappear. Whenshe felt overwhelmed she'dcuther arms andbreasts witharazor blade. She . had spent years invarious formsoftherapy andhadtried many different medications, whichhaddone littletohelp herdeal with theimprints ofher horrendou.s pastShehad also been admitted toseveral psychiatric hospitals to manage herself-destructive behaviors,againwithout muchapparent benefit Inour early therapy sessions, becauseAnniecouldonlyhintatwhat she was feeling andthinking beforeshewould shutdown andfreeze, wefocused on calming thephysiological chaoswithin. Weused every technique thatI had learned overtheyears, likebreathing withafocus onthe out breath, which activates therelaxing parasympathetic nervoussystem.Ialso taught her touse her fingers totap asequence ofacupressure pointsonvarious parts LEARNING TOINHABIT YOUR BODY:

YOGA 267 of her body, apractice oftentaught ~nderthename EFT(Emotional Freedom Technique), whichhasbeen shown tohelp patients staywithin thewindow of tolerance andoften haspositive effectsonPTSD symptoms.l THE LEGACY OFINESCAPABLE S",OCK Because wecan now identify thebrain circuits involved inthe alarm system, we know, moreorless, what washappening inAnnie's brainasshe satthat first dayinmy waiting room:Hersmoke detector, heramygdala, hadbeen re~ired tointerpret certainsituations asharbingers oflife-threatening dan- ger, and itwas sending urgentsignals toher survival braintofight, freeze, or' flee. Annie hadallthese reactions simultaneously-she wasvisibly agitated and mentally shutdown.

As we've seen,broken alarmsystems canmanifest invarious ways,and if your smoke detector malfunctions, youcannot trusttheaccuracy ofyour perceptions. Forexample, whenAnnie started tolike meshe began tolook forward toour meetings, butshewould arriveatmy office inan intense panic. Onedayshe had aflashback offeeling excited thatherfather wascom- ing home soon-but laterthatevening hemolested her.Forthefirst time, she realized thathermind automatically associatedexcitement aboutseeing someone sheloved withtheterror ofbeing molested.

Small children areparticularly adeptatcompartmentalizing experience, so that Annie's naturalloveforher father andherdread ofhis assaults were held inseparate statesofconsciousness. Asanadult Annie blamed herselffor her abuse, because shebelieved thattheloving, excited littlegirlsheonce was had ledher father on-that shehad brought themolestation uponherself.

Her rational mindtoldherthis was nonsense, butthis belief emanated from deep within heremotional, survivalbrain,fromthebasic wiring ofher limbic system. Itwould notchange untilshefeltsafe enough withinherbody to mindfully goback intothatexperience andtruly know howthatlittle girlhad felt and acted during theabuse.

THE NUMBING WITHIN One ofthe ways thememory ofhelplessness isstored isas muscle tension or feelings ofdisintegration inthe aff~~ted bodyareas: head,back,andlimbs in accident victims,vaginaandrectum invictims ofsexual abuse.Thelives of many trauma survivors cometorevolve around bracingagainstandneutral- izing unwanted sensoryexperiences, andmost people Isee inmy practice ,~I 26BTHE BODY KEEPS THESCORE have become expertsinsuch self-numbing. Theymaybecome seriallyoibese or anorexic oraddicted toexercise orwork. Atleast halfofall traumatized people trytodull their intolerable innerworld withdrugs oralcohol. Theflip side ofnumbing issensation seeking.Manypeople cutthemselves tomake the numbing goaway, while others trybungee jumping orhigh-risk activities like prostitution andgambling. Anyofthese methods cangive them afalse and paradoxical feelingofcontrol.

When peoplearechronically angryorscared, constant muscletension ultimately leadstospasms, backpain, migraine headaches, fibromyalgia, and other forms ofchronic pain.Theymayvisit multiple specialists, undergo extensive diagnostic tests,andbeprescribed multiplemedications, someof which mayprovide temporary reliefbutallofwhich failtoaddress theunder- lying issues. Theirdiagnosis willcome todefine theirreality without ever being identified asasymptom oftheir attempt tocope withtrauma.

The first twoyears ofmy therapy withAnnie focused onhelping her learn totolerate herphysical sensations forwhat theywere-just sensations in the present, withabeginning, amiddle, andanend. Weworked onhelping her stay calm enough tonotice whatshefeltwithout judgment, soshe could observe theseunbidden imagesandfeelings asresidues ?faterrible pastand not asunending threatstoher lifetoday.

Patients likeAnnie continuously challengeustofind new ways ofhelp- ing people regulate theirarousal andcontrol theirownphysiology. Thatis how myTrauma Centercolleagues andIstumbled uponyoga.

FINDING OURWAY TOYOGA:

BOTTOM-UP REGULATION Our involvement withyoga started in1998 when JimHopper andIfirst heard about anew biological marker,heartratevariability (HRV),thathadrecently been discovered tobe agood measure ofhow welltheautonomic nervous system isworking. Asyou'll recallfromchapter 5,the autonomic nervous system isour brain's mostelementary survivalsystem,itstwo branches reg- ulating. arousal throughout thebody. Roughly speaking, thesympathetic nervous system(SNS)useschemicals likeadrenaline tofuel thebody and brain totake action, whiletheparasympathetic nervoussystem(PNS)uses acetylcholine tohelp regulate basicbodyfunctions likedigestion, wound healing, andsleep anddream cycles.Whenwe'reatour best, these twosys- tems work closely together tokeep usinan optimal stateofengagement with our environment andwith ourselves.

LEARNING TOINHABIT YOURBODY: YOGA 269 Heart ratevariability measurestherelative balance between thesympa- thetic andtheparasympathetic systems.Whenweinhale, westimulate the SNS, which results inan increase inheart rate.Exhalations stimulatethe PNS, which decreases howfasttheheart beats. Inhealthy individuals inhala- tions andexhalations producesteady,rhythmical fluctuations inheart rate:

Good heartratevariability isameasure ofbasic well-being.

Why isHRV important? Whenourautonomic nervoussystemiswell balanced, wehave areasonable degreeofcontrol overourresponse to minor frustrations anddisappointments, enablingustocalmly assesswhatisgoing on when wefeel insulted orleft out. Effective arousalmodulation givesus control overourimpulses andemotions: Aslong aswe manage tostay calm, we can choose howwewant torespond. Individuals withpoorly modulated autonomic nervoussystems areeasily thrown offbalance, bothmentally and physically. Sincetheautonomic nervoussystemorganizes arousalinboth body andbrain, poorHRV-that is,alack offluctuation inheart ratein response tobreathing-not onlyhasnegative effectsonthinking andfeeling but also onhow thebody responds tostress. Lackofcoherence between breathing andheart ratemakes people vulnerable toavariety ofphysical ill- nesses, suchasheart disease andcancer, inaddition tomental problems such as depression andPTSD.2 In order tostudy thisissue further, weacquired amachine tomeasure HRV andstarted toput bands around thechests ofresearch subjectswith and without PTSDtorecord thedepth andrhythm oftheir breathing while little monitors attachedtotheir earlobes pickeduptheir pulse. Afterwe'd tested aboutsixtysubjects, itbecame clearthatpeople withPTSD have unusually lowHRY. Inother words, inPTSD thesympathetic andparasym- pathetic nervoussystems areout ofsync." Thisadded anew twist tothe complicated traumastory:Weconfirmed thatyetanother brainregulatory system wasnotfunctioning asitshould.' Failuretokeep thissystem in balance isone explanation whytraumatized peoplelikeAnnie aresovulner- able tooverrespond torelatively minorstresses: Thebiological systems that aremeant tohelp uscope withthevagaries oflife fail tomeet the challenge.

Our next scientific questionwas:Isthere away forpeople toimprove their HRV? Ihad apersonal incentive toexplore thisquestion, asIhad dis- covered thatmyown HRV wasnotnearly robust enough toguarantee long- term physical health.AnInternet searchturned upstudies showing that marathon runningmarkedly increased HRY.Sadly, thatwasof'little use,since neither Inor our patients weregood candidates forthe Boston Marathon. 270 THE BODY KEEPS THESCORE Heart ratevariability (HRV) inawell-regulated person.

Therising andfalling black linesrepresent breathing, inthis case slowandregular inhalations andexhala- tions ..The gray areashows fluctuations inheart rate.Whenever thisindividual inhales, his heart rategoes up;during exhalations theheart slows down. Thispattern ofheart rate variability reflectsexcellent physiological health.

A person withchronic 'P!SDreliving atrauma memory.

Breathinginitiallyis labored anddeep, typical ofapanic reaction. Theheart racesoutofsynch withthe breath. Thisisfollowed byrapid, shallow breathing andslow heart rate,signs thatthe person isshutting down.

Google alsolisted seventeen thousandyogasitesclaiming thatyoga improved HRV, butwewere unable tofind anysupporting studies.Yogismayhave developed awonderful methodtohelp people findinternal balanceand health, butback in1998 notmuch workhadbeen done onevaluating their claims withthetools ofthe Western medicaltradition.

Since then,however, scientific methodshaveconfirmed thatchanging LEARNING TOINHABIT YOURBODY: YOGA 271 the way onebreathes canimprove problems withanger, depression, andanx- iety? andthatyoga canpositively affectsuchwide-ranging medicalproblems as high blood pressure, elevatedstresshormone secretion," asthma,andlow- back pain,? However, nopsychiatric journalhadpublished ascientific study of yoga forPTSD untilourown work appeared in2014.

8 As ithappened, afew days after ourInternet searchalanky yogateacher named DavidEmerson walkedthrough thefront doorofthe Trauma Center.

He told usthat he'd developed amodified formofhatha yogatodeal with PTSD andthat he'd' been holding classesforveterans atalocal vetcenter and for women inthe Boston AreaRape Crisis Center. Wouldwebeinterested in working withhim? Dave's visiteventually grewintoavery active yogapro- gram, andindue course wereceived thefirst grant fromtheNational Insti- tutes ofHealth tostudy theeffects ofyoga onPTSD. Dave's workalso contributed tomy developing myown regular yogapractice andbecoming a frequent teacheratKripalu, ayoga center inthe Berkshire Mountains in western Massachusetts. (Alongtheway, myown HRV pattern improved as well.) .

In choosing toexplore yogatoimprove HRVwewere taking anexpan- sive approach tothe problem. Wecould simply haveused anyofanumber of reasonably pricedhandheld devicesthattrain people toslow their breathing and synchronize itwith their heart rate,resulting inastate of"cardiac coher- ence" likethepattern showninthe first illustration above."Todaytherearea variety ofapps thatcanhelp improve HRVwiththeaidofasmartphone.

lO In our clinic wehave workstations wherepatients cantrain their HRV, andI urge all my patients who,forone reason oranother, cannotpractice yoga, martial arts,orqigong totrainthemselves athome. (SeeResources formore information.) EXPLORING YOGA Our decision tostudy yogaledusdeeper intotrauma's impactonthe body.

Our first experimental yogaclasses metinaroom generously donatedbya nearby studio. DavidEmerson andhiscolleagues DanaMoore andJodi Carey volunteered asinstructors, andmyresearch teamfigured outhow wecould best measure yoga'seffects onpsychologicaUtmctioning. Weputflyers in neighborhood supermarketsandlaundromats toadvertise ourclasses and interviewed dozensofpeople whocalled inresponse. Ultimately weselected thirty-seven womenwhohadsevere trauma histories andwho hadalready .

, 272THE BODY KEEPS THESCORE received manyyearsoftherapy without muchbenefit. Halfthevolunteers were selected atrandom forthe yoga group, whiletheothers would receive a well-established mentalhealthtreatment, dialecticalbehaviortherapy (DBT), whichteaches peoplehowtoapply mindfulness tostay calm andin control. Finally,wecommissioned anengineer atMIT tobuild usacompli- cated computer thatcould measure HRVsimultaneously ineight different people. (Ineach study group thereweremultiple classes,eachwith nomore than eight participants.) Whileyogasignificantly improvedarousalproblems in PTSD anddramatically improvedoursubjects' relationships totheir bod- .

ies ("Inow takecareofmy body"; "Ilisten towhat mybody needs"), eight weeks ofDBT didnot affect theirarousal levelsorPTSD symptoms. Thus, our interest inyoga gradually evolvedfromafocus onlearning whetheryoga can change HRV(which itcan)" tohelping traumatized peoplelearntocom- fortably inhabittheirtortured bodies.

Over timewealso started ayoga program formarines atCamp Lejeune and have worked successfully withvarious otherprograms toimplement yoga programs forveterans withPTSD. Eventhough wehave noformal research dataonthe veterans, itlooks asifyoga isat least aseffective forthem as ithas been forthe women inour studies.

All yoga programs consistofacombination ofbreath practices (pranayama), stretchesorpostures (asanas), andmeditation. Different schools ofyoga emphasize variationsinintensity andfocus within thesecore components. Forexample, variations inthe speed anddepth ofbreathing and use ofthe mouth, nostrils, andthroat allproduce different results,andsome techniques havepowerful effectsonenergy." inour classes wekeep the approach simple.Manyofour patients arebarely awareoftheir breath, so learning tofocus onthe inand outbreath, tonotice whether thebreath was fast orslow, andtocount breaths insome poses canbeasignificant accorn- plishment." Wegradually introduce a limited number ofclassic postures. Theempha- sis isnot ongetting theposes "right" butonhelping theparticipants notice which muscles areactive atdifferent times.Thesequences aredesigned to create arhythm between tensionandrelaxation-something wehope they will begin toperceive intheir day-to-day lives.

We donot teach meditation assuch, butwedofoster mindfulness by encouraging studentstoobserve whatishappening indifferent partsofthe body from posetopose. Inour studies wekeep seeing howdifficult itis for traumatized peopletofeel completely relaxedandphysically safeintheir LEARNING TOINHABIT YOURBODY: YOGA 273 bodies. Wemeasure oursubjects' HRVbyplacing tinymonitors ontheir arms during shavasana, thepose atthe end ofmost classes duringwhich practitioners lieface up,palms up,arms andlegs relaxed. Insteadofrelax- ation wepicked uptoo much muscle activity toget aclear signal. Ratherthan going intoastate ofquiet repose, ourstudents' musclesoftencontinue to prepare themtofight unseen enemies. Amajor challenge inrecovering from trauma remains beingabletoachieve astate oftotal relaxation andsafe sur- render.

LEARNING SELF-REGULATION After seeing thesuccess ofour pilot studies, weestablished atherapeutic yoga program atthe Trauma Center.Ithought thatthismight bean oppor- tunity forAnnie todevelop amore caring relationship withherbody, andI urged hertotry it.The first class wasdifficult. Merelybeinggivenanadjust- ment bythe instructor wassoterrifying thatshewent home andslashed herself-her malfunctioning alarmsystem interpreted evenagentle touch on her back asan assault. Atthe same timeAnnie realized thatyoga might offerheraway toliberate herselffromtheconstant senseofdanger that shefeltinher body. With myencouragement shereturned thefollow- ing week.

Annie hadalways founditeasier towrite about herexperiences thanto talk about them. Afterhersecond yogaclass shewrote tome: "Idon't know all ofthe reasons thatyoga terrifies mesomuch, butIdo know thatitwill be an incredible sourceofhealing forme and that iswhy Iam working on myself totry it.Yoga isabout looking inwardinstead ofoutward andlis- tening tomy body, andalot ofmy survival hasbeen geared around never doing thosethings. Goingtothe class today myheart wasracing andpart of me really wanted toturn around, butthen Ijust kept putting onefoot in front ofthe other untilIgot tothe door andwent in.After theclass Icame home andslept forfour hours. Thisweek Itried doing yogaathome and the words cametome 'Your bodyhasthings tosay.' Isaid back tomyself, 'I will tryand listen." A few days laterAnnie wrote: "Somethoughts duringandafter yoga today. Itoccurred tome how disconnected Imust befrom mybody when I cut it.When Iwas doing theposes Inoticed thatmyjaw andthewhole area from where mylegs endtomy bellybutton iswhere Iam tight, tense and holding thepain andmemories. Sometimes youhave asked me 274THE BODY KEEPS THESCORE where Ifeel things andIcan't evenbegin tolocate them,buttoday Ifelt those places 'veryclearly anditmade mewant tocry inagentle kind of way." 'The following monthbothofus went onvacation and,invited tostay in touch, Annie wrotetome again: "I'vebeen doing yogaonmy own inaroom that overlooks thelake. I'mcontinuing toread thebook youlent me[Stephen Cope's wonderful YogaandtheQuestfor theTrue Self]. It'sreally interesting to think about howmuch Ihave been refusing tolisten tomy body, which is such animportant partofwho Iam. Yesterday whenIdid yoga Ithought aboutletting mybody tellmethe story itwants totell and inthe hipopening poses therewasalot ofpain andsadness. Idon't think mymind isgoing to let really vividimages comeupaslong asIam away fromhome, which is good. Ithink nowabout howunbalanced Ihave been andabout howhard I have tried todeny thepast, which isapart ofmy true self.There isso much I can learn ifIam open toitand then Iwon't havetofight myself everymin- ute ofevery day." , One ofthe hardest yogapositions forAnnie totolerate wasonethat's often called Happy Baby,inwhich youlieon your backwithyourknees deeply bentandthesoles ofyour feetpointing tothe ceiling, whilehold- ing your toeswith your hands. 'Thisrotates thepelvis intoawide-open position. It'seasy tounderstand whythiswould makearape victim feel extremely vulnerable. Yet,aslong asHappy Baby(orany posture thatresem- bles it)precipitates intensepanic,itis difficult tobe intimate. Learninghow to comfortably assumeHappyBabyisachallenge formany patients inour yoga classes.

GETTING ,TO KNOW ME:

CULTIVATING INTEROCEPTION One ofthe clearest lessonsfromcontemporary neuroscienceisthat oursense of ourselves isanchored inavital connection withourbodies." Wedonot truly know ourselves unlesswecan feeland interpret ourphysical sensations; we need toregister andactonthese sensations tonavigate safelythrough life," While numbing (orcompensatory sensationseeking)maymake lifetol- erable, theprice youpayisthat youlose awareness ,ofwhat isgoing oninside your body and,with that, thesense ofbeing fully,sensually alive.

In chapter 6 I discussed alexithymia, thetechnical termfornot being able toidentify whatisgoing oninside oneself," Peoplewhosuffer from LEARNING TOIN'HABIT YOURBODY: YOGA alexithymia tendtofeel physically uncomfortable butcannot describe exactly what theproblem is.As aresult theyoften havemultiple vagueanddistress- ing physical complaints thatdoctors can'tdiagnose. Inaddition, theycan't figure outforthemselves whatthey're reallyfeeling aboutanygiven situation or what makes themfeelbetter orworse. Thisisthe result ofnumbing, which keeps themfromanticipating andresponding tothe ordinary demandsof their bodies inquiet, mindful ways.Atthe same time,itmuffles theeveryday sensory delights ofexperiences likemusic, touch,andlight, which imbue life with value. Yogaturned outtobe aterrific wayto(relgain arelationship with theinterior worldandwith itacaring, loving,sensual relationship to the self.

If you arenot aware ofwhat yourbody needs, youcan't takecareofit.If you don't feelhunger, youcan't nourish yourself. Ifyou mistake anxietyfor hunger, youmay eattoo much. Andifyou can't feelwhen you're satiated, you'll keepeating. Thisiswhy cultivating sensoryawareness issuch acritical aspect oftrauma recovery. Mosttraditional therapiesdownplay orignore the moment-to-moment shiftsinour inner sensory world.Butthese shifts'carry the essence ofthe organism'~ responses:theemotional statesthatare impririted inthe body's chemical profile,inthe viscera, inthe contraction of the striated muscles ofthe face, throat, trunk,andlimbs.'? Traumatized peo- ple need tolearn thatthey cantolerate theirsensations, befriendtheirinner experiences, andcultivate newaction patterns.

In yoga youfocus yourattention onyour breathing andonyour sensa- tions moment tomoment. Youbegin tonotice theconnection betweenyour emotions andyour body-perhaps howanxiety aboutdoing apose actually throws youoffbalance. Youbegin toexperiment withchanging theway you feel. Will taking adeep breath relieve thattension inyour shoulder? Will focusing onyour exhalations produceasense ofcalm?" Simply noticing whatyoufeelfosters emotional regulation, andithelps you tostop trying toignore whatisgoing oninside you.AsIoften tellmy students, thetwo most important phrasesintherapy, asinyoga, are"Notice that:' and"What happens next?"Onceyoustart approaching yourbodywith curiosity ratherthanwithfear,everything shifts.

Body awareness alsochanges yoursense oftime. Trauma makesyoufeel as ifyou arestuck forever inahelpless stateofhorror. Inyoga youlearn that sensations risetoapeak andthen fall.Forexample, ifan instructor invites you toenter aparticularly challenging position,youmay atfirst feelasense of defeat orresistance, anticipating thatyouwon't beable totolerate the 275 276 THEBODY KEEPS THESCORE feelings brought upby this particular position.Agood yogateacher will encourage youtojust notice anytension whiletiming whatyoufeelwith the flow ofyour breath: "We'llbeholding thisposition forten breaths." Thishelps you anticipate theend ofdiscomfort andstrengthens yourcapacity todeal with physical andemotional distress.Awareness thatallexperience istransi- tory changes yourperspective onyourself. .

This isnot tosay that regaining interoception isn'tpotentially upsetting.

What happens whenanewly accessed feelinginyour chest isexperienced as rage, orfear, oranxiety? Inour first yoga study wehad a50 percent dropout rate, thehighest ofany study we'deverdone. When weinterviewed the patients who'dleft,welearned thatthey hadfound theprogram toointense:

Any posture thatinvolved. thepelvis couldprecipitate intensepanicor even flashbacks tosexual assaults. Intensephysical sensations unleashedthe demons fromthepast that hadbeen socarefully keptincheck bynumbing and inattention. Thistaught ustogo slow, often atasnail's pace.That approach paidoff:Inour most recent studyonlyoneoutofthirty-four par- ticipants didnot finish.

Yoga Participants (n=6)Greater ThanControl (n=2), Post-Yoga GreaterThanPre-Yoga left insula right thalamus right dorsomedial prefrontalcortex Effects ofaweekly yogaclass.

Aftertwenty weeks,chronically trauma- tized women developed increasedactivation ofcritical brainstructures involved inself-regulation: theInsula andthemedial prefrontal cortex.

LEARNING TOINHABIT YOURBODY: YOGA 277 YOGA AND.THE NEUROSCIENCE OF SELF-AWARENESS During thepast fewyears brainresearchers suchasmy colleagues SaraLazar and Britta Holzel atHarvard haveshown thatintensive meditation hasa positive effectonexactly thosebrain areasthatarecritical forphysiological self-regulation." Inour latest yogastudy, withsixwomen withhistories of profound earlytrauma, wealso found thefirst indications thattwenty weeks ofyoga practice increased activation ofthe basic self-system, the insula andthemedial prefrontal cortex(seechapter 6).This research needs.

much morework, butitopens upnew perspectives onhow actions that involve noticing andbefriending thesensations inour bodies canproduce profound changesinboth mind andbrain thatcanlead tohealing from trauma.

After eachofour yoga studies, weasked theparticipants whateffect the classes hadhad onthem. Wenever mentioned theinsula orinteroception; in fact, wekept thediscussion andexplanation toaminimum sothat they could focus inward.

Here isasample oftheir responses:

• "My emotions feelmore powerful. Maybeit'sjust that Ican recognize.

them now." • "I can express myfeelings morebecause Ican recognize themmore. I feel them inmy body, recognize them,andaddress them." • "1 now seechoices, multiple paths.Ican decide andIcan choose mylife, it doesn't havetobe repeated orbe experienced likeachild." • "I was able tomove mybody aridbeinmy body inasafe place andwith- out hurting myself!gettinghurt." LEARNING TOCOMMUNICATE People whofeelsafe intheir bodies canbegin totranslate thememories that previously overwhelmed themintolanguage. AfterAnnie hadbeen practicing yoga three times aweek forabout ayear, shenoticed thatshewas able totalk much motefreely tome about whathadhappened toher. Shethought this almost miraculous. Oneday,when sheknocked overaglass ofwater, Igot up from mychair andapproached herwith aKleenex box,saying, "Letmeclean that up." This precipitated abrief, intense panicreaction. Shewas quickly ableto 278THE BODY KEEPS THESCORE contain herself,though, andexplained whythose particular wordswereso upsetting toher-they werewhat herfather would sayafter he'draped her.

Annie wrotetome after thatsession: "Didyounotice thatIhave been abletosay the words outloud? Ididn't havetowrite them down totell you what washap- pening. Ididn't losetrust inyou because yousaid words thattriggered me.I understood thatthewords wereatrigger andnotterrible words thatnoone should say." Annie continues topractice yogaandtowrite tome about herexperi- ences: "Today Iwent toamorning yogaclass atmy new yoga s~udio.The teacher talkedaboutbreathing tothe edge ofwhere wecan and then noticing that edge. Shesaid that ifwe notice ourbreath weare inthe present because we can't breathe inthe future orthe past. Itfelt soamazing tome tobe prac- ticing breathing inthat wayafter wehad just talked aboutit,like Ihad been given a~ift. Some ofthe poses canbetriggering forme. Two ofthem were today, onewhere yourlegsareupfrog likeand onewhere youaredoing really deep breathing intoyour pelvis. Ifelt the beginning ofpanic, especially inthe breathing pose,likeohno that's notapart ofmy body Iwant tofeel. Butthen I was able tostop myself andjust say,notice thatthispart ofyour body is holding experiences andthen justletitgo. You don't havetostay there but you don't havetoleave either, justuseitas information. Idon't know thatI have everbeen abletodo that insuch aconscious waybefore. Itmade me think thatifInotice without beingsoafraid, itwill beeasier formetobelieve myself." .In another message, Anniereflected onthe changes inher life: "Islowly learned tojust have myfeelings; withoutbeinghijacked bythem. Lifeismore manageable: Iam more attuned tomy day and more present inthe moment.

I am more tolerant ofphysical touch.Myhusband andIare enjoying watch- ing movies cuddled together inbed ...ahuge step.Allthis helped mefinally feel intimate withmyhusband." 1.<,. ------••.•.• CHAPTER 17 PUTTING THEPIECES TOGETHER:

SELF-LEADERSHIP This being human isaguest house. Everymorning isanew arrival. A joy, adepression, ameanness, somemomentary awarenesscomesas an unexpected visitor....Welcome andentertain themall.Treat each guest honorably. Thedark thought, theshame, themalice, meetthem at the door laughing, andinvite themin.Begrateful forwhoever comes, because eachhasbeen sentasaguide frombeyond.

-Rumi A man hasasmany social selvesasthere areindividuals whorecog- nize him.

-WilliamJames, ThePrinciples of Psydlo/ogy I t was early inmy career, ardIhad been seeing Mary,ashy, lo.nely, andphysi- cally collapsed youngwoman, forabout threemonths mweekly psy- chotherapy, dealingwiththeravages ofher terrible historyofearly abuse.

One dayIopened thedoor tomy waiting roomandsawherstanding there provocatively, dressedinaminiskirt, herhair dyed flaming red,with acup of coffee inone hand andasnarl onher face. "You must beDr. van derKolk," she said. "Myname isJane, andIcame towarn younottobelieve anyofthe lies tha~ Mary hasbeen telling you.CanIcome inand tellyou about her?"I was stunned butfortunately keptmyself fromconfronting "Jane"andinstead