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- CHAPTER 1 LESSONS FROM VIETNAM VETERANS I became what I am today at the age of twelve, on a frigid overcast day in the winter of 1975. . . . That was a long time ago, but it’s wrong what they say about the past. . . . Looking back now, I realize I have been peeking into that deserted alley for the last twenty-six years. —Khaled Hosseini, The Kite Runner Some people’s lives seem to flow in a narrative; mine had many stops and starts. That’s what trauma does. It interrupts the plot. . .. It just happens, and then life goes on. No one prepares you for it. —Jessica Stern, Denial: A Memoir of Terror The Tuesday after the Fourth of July weekend, 1978, was my first day as a staff psychiatrist at the Boston Veterans Administration Clinic. As I was hanging a reproduction of my favorite Breughel painting, “The Blind Lead- ing the Blind,” on the wall of my new office, I heard a commotion in the reception area down the hall. A moment later a large, disheveled man in a stained three-piece suit, carrying a copy of Soldier of Fortune magazine under his arm, burst thrdugh my door. He was so agitated and so clearly hungover that I wondered how I could possibly help this hulking man. I asked him to take a seat, and tell me what I could do for him. His name was Tom. Ten years earlier he had been in the Marines, doing

8 THE BODY KEEPS THE SCORE his service in Vietnam. He had spent the holiday weekend holed up in his downtown-Boston law office, drinking and looking at old photographs, rather than with his family. He knew from previous years’ experience that the noise, the fireworks, the heat, and the picnic in his sister’s backyard against the backdrop of dense early-summer foliage, all of which reminded him of Viet- nam, would drive him crazy. When he got upset he was afraid to be around his family because he behaved like a monster with his wife and two young boys. The noise of his kids made him so agitated that he would storm out of the house to keep himself from hurting them. Only drinking himself into oblivion or riding his Harley-Davidson at dangerously high speeds helped him to calm down. Nighttime offered no relief—his sleep was constantly interrupted by nightmares about an ambush in a rice paddy back in "Nam, in which all the members of his platoon were killed or wounded. He also had terrifying flash- backs in which he saw dead Vietnamese children. The nightmares were so horrible that he dreaded falling asleep and he often stayed up for most of the night, drinking. In the morning his wife would find him passed out on the living room couch, and she and the boys had to tiptoe around him while she made them breakfast before taking them to school. Filling me in on his background, Tom said that he had graduated from high school in 1965, the valedictorian of his class. In line with his family tra- dition of military service he enlisted in the Marine Corps immediately after graduation. His father had served in World War II in General Patton’s army, and Tom never questioned his father’s expectations. Athletic, intelligent, and an obvious leader, Tom felt powerful and effective after finishing basic train- ing, a member of a team that was prepared for just about anything. In Viet- nam he quickly became a platoon leader, in charge of eight other Marines. Surviving slogging through the mud while being strafed by machine-gun fire can leave people feeling pretty good about themselves—and their comrades. At the end of his tour of duty Tom was honorably discharged, and all he wanted was to put Vietnam behind him. Outwardly that’s exactly what he did. He attended college on the GI Bill, graduated from law school, married his high school sweetheart, and had two sons. Tom was upset by how difficult it was to feel any real affection for his wife, even though her letters had kept him alive in the madness of the jungle. Tom went through the motions of living a normal life, hoping that by faking it he would learn to become his old self again. He now had a thriving law practice and a picture-perfect family, but he sensed he wasn’t normal; he felt dead inside. Although Tom was the first veteran I had ever encountered on a LESSONS FROM VIETNAM VETERANS o professional basis, many aspects of his story were familiar to me. I grew up in postwar Holland, playing in bombed-out buildings, the son of a man who had been such an outspoken opponent of the Nazis that he had been sent to an internment camp. My father never talked about his war experiences, but he was given to outbursts of explosive rage that stunned me as a little boy. How could the man I heard quietly going down the stairs every morning to pray and read the Bible while the rest of the family slept have such a terrifying temper? How could someone whose life was devoted to the pursuit of social justice be so filled with anger? I witnessed the same puzzling behavior in my uncle, who had been captured by the Japanese in the Dutch East Indies (now Indonesia) and sent as a slave laborer to Burma, where he worked on the fa- mous bridge over the river Kwai. He also rarely mentioned the war, and he, too, often erupted into uncontrollable rages. As I listened to Tom, I wondered if my uncle and my father had had nightmares and flashbacks—if they, too, had felt disconnected from their loved ones and unable to find any real pleasure in their lives. Somewhere in the back of my mind there must also have been my memories of my frightened—and often frightening—mother, whose own childhood trauma was sometimes alluded to and, I now believe, was frequently reenacted. She had the unnerving habit of fainting when I asked her what her life was like as a little girl and then blaming me for making her so upset. Reassured by my obvious interest, Tom settled down to tell me just how scared and confused he was. He was afraid that he was becoming just like his father, who was always angry and rarely talked with his children—except to compare them unfavorably with his comrades who had lost their lives around Christmas 1944, during the Battle of the Bulge. As the session was drawing to a close, I did what doctors typically do: I focused on the one part of Tom’s story that I thought I understood—his night- mares. As a medical student I had worked in a sleep laboratory, observing people’s sleep/dream cycles, and had assisted in writing some articles about nightmares. I had also participated in some early research on the beneficial effects of the psychoactive drugs that were just coming into use in the 1970s. So, while I lacked a true grasp of the scope of Tom’s problems, the nightmares were something I could relate to, and as an enthusiastic believer in better living through chemistry, I prescribed a drug that we had found to be effec- tive in reducing the incidence and severity of nightmares. I scheduled Tom for a follow-up visit two weeks later. When he returned for his appointment, I eagerly asked Tom how the medicines had worked. He told me he hadn't taken any of the pills. Trying to

12 THE BODY KEEPS THE SCORE occurs only in faraway places like Darfur or the Congo. It is hard enough for observers to bear witness to pain. Is it any wonder, then, that the traumatized individuals themselves cannot tolerate remembering it and that they often resort to using drugs, alcohol, or self-mutilation to block out their unbearable knowledge? Tom and his fellow veterans became my first teachers in my quest to understand how lives are shattered by overwhelming experiences, and in fig- uring out how to enable them to feel fully alive again. TRAUMA AND THE LOSS OF SELF The first study I did at the VA started with systematically asking veterans what had happened to them in Vietnam. I wanted to know what had pushed them over the brink, and why some had broken down as a result of that experience while others had been able to go on with their lives.” Most of the men | interviewed had gone to war feeling well prepared, drawn close by the rigors of basic training and the shared danger. They exchanged pictures of their families and girlfriends; they put up with one another’s flaws. And they were prepared to risk their lives for their friends. Most of them confided their dark secrets to a buddy, and some went so far as to share each other’s shirts and socks. _ Many of the men had friendships similar to Tom’s with Alex. Tom met Alex, an Italian guy from Malden, Massachusetts, on his first day in country, and they instantly became close friends. They drove their jeep together, lis- tened to the same music, and read each other’s letters from home. They got drunk together and chased the same Vietnamese bar girls. After about three months in country Tom led his squad on a foot patrol through a rice paddy just before sunset. Suddenly a hail of gunfire spurted from the green wall of the surrounding jungle, hitting the men around him one by one. Tom told me how he had looked on in helpless horror as all the members of his platoon were killed or wounded in a matter of seconds. He would never get one image out of his mind: the back of Alex’s head as he lay facedown in the rice paddy, his feet in the air. Tom wept as he recalled, “He was the only real friend I ever had.” Afterward, at night, Tom continued to hear the screams of his men and to see their bodies falling into the water. Any sounds, smells, or images that reminded him of the ambush (like the popping of firecrackers on the Fourth of July) made him feel just as paralyzed, ter- rified, and enraged as he had the day the helicopter evacuated him from the rice paddy. LESSONS FROM VIETNAM VETERANS 13 Maybe even worse for Tom than the recurrent flashbacks of the ambush was the memory of what happened afterward. I could easily imagine how Tom’s rage about his friend’s death had led to the calamity that followed. It took him months of dealing with his paralyzing shame before he could tell me about it. Since time immemorial veterans, like Achilles in Homer’s Iliad, have responded to the death of their comrades with unspeakable acts of revenge. The day after the ambush Tom went into a frenzy to a neighboring village, killing children, shooting an innocent farmer, and raping a Vietnam- ese woman. After that it became truly impossible for him to go home again in any meaningful way. How can you face your sweetheart and tell her that you brutally raped a woman just like her, or watch your son take his first step when you are reminded of the child you murdered? Tom experienced the death of Alex as if part of himself had been forever destroyed—the part that was good and honorable and trustworthy. Trauma, whether it is the result of something done to you or something you yourself have done, almost always makes it difficult to engage in intimate relationships. After you have experi- enced something so unspeakable, how do you learn to trust yourself or anyone else again? Or, conversely, how can you surrender to an intimate rela- tionship after you have been brutally violated? Tom kept showing up faithfully for his appointments, as I had become for him a lifeline—the father he’d never had, an Alex who had survived the ambush. It takes enormous trust and courage to allow yourself to remember. One of the hardest things for traumatized people is to confront their shame about the way they behaved during a traumatic episode, whether it is objec- tively warranted (as in the commission of atrocities) or not (as in the case of a child who tries to placate her abuser). One of the first people to write about this phenomenon was Sarah Haley, who occupied an office next to mine at the VA Clinic. In an article entitled “When the Patient Reports Atrocities,™ which became a major impetus for the ultimate creation of the PTSD diag- nosis, she discussed the well-nigh intolerable difficulty of talking about (and listening to) the horrendous acts that are often committed by soldiers in the course of their war experiences. It’s hard enough to face the suffering that has been inflicted by others, but deep down many traumatized people are even more haunted by the shame they feel about what they themselves did or did not do under the circumstances. They despise themselves for how terrified, dependent, excited, or enraged they felt. In later years I encountered a similar phenomenon in victims of child abuse: Most of them suffer from agonizing shame about the actions they took to survive and maintain a connection with the person who abused them.

14 THE BODY KEEPS THE SCORE This was particularly true if the abuser was someone close to the child, some- one the child depended on, as is so often the case. The result can be confusion about whether one was a victim or a willing participant, which in turn leads to bewilderment about the difference between love and terror; pain and plea- sure. We will return to this dilemma throughout this book. NUMBING Maybe the worst of Tom’s symptoms was that he felt emotionally numb. He desperately wanted to love his family, but he just couldnt evoke any deep feelings for them. He felt emotionally distant from everybody, as though his heart were frozen and he were living behind a glass wall. That numbness extended to himself, as well. He could not really feel anything except for his momentary rages and his shame. He described how he hardly recognized himself when he looked in the mirror to shave. When he heard himself argu- ing a case in court, he would observe himself from a distance and wonder how this guy, who happened to look and talk like him, was able to make such cogent arguments. When he won a case he pretended to be gratified, and when he lost it was as though he had seen it coming and was resigned to the | defeat even before it happened. Despite the fact that he was a very effective lawyer, he always felt as though he were floating in space, lacking any sense of purpose or direction. | - The only thing that occasionally relieved this feehng of aimlessness was intense involvement in a particular case. During the course of our treatment Tom had to defend a mobster on a murder charge. For the duration of that trial he was totally absorbed in devising a strategy for winning the case, and there were many occasions on which he stayed up all night to immerse him- self in something that actually excited him. It was like being in combat, he said—he felt fully alive, and nothing else mattered. The moment Tom won that case, however, he lost his energy and sense of purpose. The nightmares returned, as did his rage attacks—so intensely that he had to move into a motel to ensure that he would not harm his wife or children. But being alone, too, was terrifying, because the demons of the war returned in full force. Tom tried to stay busy, working, drinking, and drugging—doing anything to avoid confronting his demons. He kept thumbing through Soldier of Fortune, fantasmng about enlist- ing as a mercenary in one of the many regional wars then raging in Africa. That spring he took out his Harley and roared up the Kancamagus Highway in New Hampshire. The vibrations, speed, and danger of that ride helped LESSONS FROM VIETNAM VETERANS 15 him pull himself back together, to the point that he was able to leave his motel room and return to his famlly THE REORGANIZATION OF PERCEPTION Another study I conducted at the VA started out as research about night- mares but ended up exploring how trauma changes people’s perceptions and imagination. Bill, a former medic who had seen heavy action in Vietnam a decade earlier, was the first person enrolled in my nightmare study. After his discharge he had enrolled in a theological seminary and had been assigned to his first parish in a Congregational church in a Boston suburb. He was doing fine until he and his wife had their first child. Soon after the baby’s birth, his wife, a nurse, had gone back to work while he remained at home, working on his weekly sermon and other parish duties and taking care of their newborn. On the very first day he was left alone with the baby, it began to cry, and he found himself suddenly flooded with unbearable images of dying children in Vietnam. Bill had to call his wife to take over child care and came to the VA in a panic. He described how he kept hearing the sounds of babies crying and seeing images of burned and bloody children’s faces. My medical colleagues thought that he must surely be psychotic, because the textbooks of the time said that auditory and visual hallucinations were symptoms of paranoid schizophrenia. The same texts that provided this diagnosis also supplied a cause: Bill’s psychosis was probably triggered by his feeling dlsplaced in his wife’s affections by their new baby. Aslarrived at the intake office that day, I saw Bill surrounded by worried doctors who were preparing to inject him with a powerful antipsychotic drug and ship him off to a locked ward. They described his symptoms and asked my opinion. Having worked in a previous job on a ward specializing in the treatment of schizophrenics, I was intrigued. Something about the diagnosis didn't sound right. I asked Bill if I could talk with him, and after hearing his story, I unwittingly paraphrased something Sigmund Freud had said about trauma in 1895: “I think this man is suffering from memories.” I told Bill that I would try to help him and, after offering him some medications to control his panic, asked if he would be willing to come back a few days later to par- ticipate in my nightmare study.® He agreed. | As part of that study we gave our participants a Rorschach test.6 Unlike tests that require answers to straightforward questions, responses to the Rorschach are almost impossible to fake. The Rorschach provides us with a

18 THE BODY KEEPS THE SCORE speak flatly declared, “I do not want to talk about the war.” I replied that the members could discuss anything they wanted. After half an hour of excru- ciating silence, one veteran finally started to talk about his helicopter crash. To my amazement the rest immediately came to life, speaking with great intensity about their traumatic experiences. All of them returned the follow- ing week and the week after. In the group they found resonance and meaning in what had previously been only sensations of terror and emptiness. They felt a renewed sense of the comradeship that had been so vital to their war experience. They insisted that I had to be part of their newfound unit and gave me a Marine captain’s uniform for my birthday. In retrospect that ges- ture revealed part of the problem: You were either in or out—you either belonged to the unit or you were nobody. After trauma the world becomes sharply divided between those who know and those who don't. People who have not shared the traumatic experience cannot be trusted, because they can’t understand it. Sadly, this often includes spouses, children, and co-workers. A ‘ Later I led another group, this time for veterans of Patton’s army—men now well into their seventies, all old enough to be my father. We met on Mon- day mornings at eight o'clock. In Boston winter snowstorms occasionally paralyze the public transit system, but to my amazement all of them showed up even during blizzards, some of them trudging several miles through the snow to reach the VA Clinic. For Christmas they gave me a 1940s Gl-issue wristwatch. As had been the case with my group of Marines, I could not be their doctor unless they made me one of them. ‘ Moving as these experiences were, the limits of group therapy became clear when I urged the men to talk about the issues they confronted in their daily lives: their relationships with their wives, children, girlfriends, and fam- ily; dealing with their bosses and finding satisfaction in their work; their heavy use of alcohol. Their typical response was to balk and resist and instead recount yet again how they had plunged a dagger through the heart of a Ger- man soldier in the Hiirtgen Forest or how their helicopter had been shot down in the jungles of Vietnam. Whether the trauma had occurred ten years in the past or more than forty, my patients could not bridge the gap between their wartime experi- ences and their current lives. Somehow the very event that caused them so much pain had also become their sole source of meaning. They felt fully alive only when they were revisiting their traumatic past. LESSONS FROM VIETNAM VETERANS 19 DIAGNOSING POSTTRAUMATIC STRESS In those early days at the VA, we labeled our veterans with all sorts of diagnoses—alcoholism, substance abuse, depression, mood disorder, even schizophrenia—and we tried every treatment in our textbooks. But for all our efforts it became clear that we were actually accomplishing very little. The powerful drugs we prescribed often left the men in such a fog that they could barely function. When we encouraged them to talk about the precise details of a traumatic event, we often inadvertently triggered a full-blown flashback, rather than helping them resolve the issue. Many of them dropped out of treatment because we were not only failing to help but also sometimes making things worse. A turning point arrived in 1980, when a group of Vietnam veterans, aided by the New York psychoanalysts Chaim Shatan and Robert J. Lifton, successfully lobbied the American Psychiatric Association to create a new diagnosis: posttraumatic stress disorder (PTSD), which described a cluster of symptoms that was common, to a greater or lesser extent, to all of our veter- ans. Systematically identifying the symptoms and grouping them together into a disorder finally gave a name to the suffering of people who were over- whelmed by horror and helplessness. With the conceptual framework of PTSD in place, the stage was set for a radical change in our understanding of our patients. This eventually led to an explosion of research and attempts at finding effective treatments. Inspired by the possibilities presented by this new diagnosis, I proposed a study on the biology of traumatic memories to the VA. Did the memories of those suffering from PTSD differ from those of others? For most people the memory of an unpleasant event eventually fades or is transformed into some- thing more benign. But most of our patients were unable to make their past into a story that happened long ago.” The opening line of the grant rejection read: “It has never been shown that PTSD is relevant to the mission of the Veterans Administration.” Since then, of course, the mission of the VA has become organized around the diagnosis of PTSD and brain injury, and considerable resources are dedicated to applying “evidence-based treatments” to traumatized war veterans. But at the time things were different and, unwilling to keep working inan organiza- tion whose view of reality was so at odds with my own, I handed in my resig- nation; in 1982 I took a position at the Massachusetts Mental Health Center, the Harvard teaching hospital where I had trained to become a psychiatrist.

20 THE BODY KEEPS THE SCORE My new responsibility was to teach a fledgling area of study: psychopharma- cology, the administration of drugs to alleviate mental illness. In my new job I was confronted on an almost daily basis with issues I thought I had left behind at the VA. My experience with combat veterans had so sensitized me to the impact of trauma that I now listened with a very dif- ferent ear when depressed and anxious p.étients told me stories of molesta- tion and family violence. I was particularly struck by how many female patients spoke of being sexually abused as children. This was puzzling, as the standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, occurring about once in every million women.® Given that there were then only about one hundred million women living in the United States, I wondered how forty seven, almost half of them, had found their way to my office in the basement of the hospital. Furthermore, the textbook said, “There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology.” My patients with incest histories were hardly free of “subsequent psycho- pathology”’—they were profoundly depressed, confused, and often engaged in bizarrely self-harmful behaviors, such as cutting themselves with razor blades. The textbook went on to practically endorse incest, explaining that “such incestuous activity diminishes the subject’s chance of psychosis and allows for a better adjustment to the external world.” In fact, as it turned out, incest had devastating effects on women'’s well-being. | In many ways these patients were not so different from the veterans I had just left behind at the VA. They also had nightmares and flashbacks. They also alternated between occasional bouts of explosive rage and long periods of being emotionally shut down. Most of them had great difficulty getting along with other people and had trouble maintaining meaningful relation- ships. As we now know, war is not the only calamity that leaves human lives in ruins. While about a quarter of the soldiers who serve in war zones are expected to develop serious posttraumatic problems,' the majority of Amer- icans experience a violent crime at some time during their lives, and more accurate reporting has revealed that twelve million women in the United States have been victims of rape. More than half of all rapes occur in girls below age fifteen."! For many people the war begins at home: Each year about three million children in the United States are reported as victims of child abuse and neglect. One million of these cases are serious and credible enough to force local child protective services or the courts to take action.’ In other words, for every soldier who serves in a war zone abroad, there are LESSONS FROM VIETNAM VETERANS 21 ten children who are endangered in their own homes. This is particularly tragic, since it is very difficult for growing children to recover when the source of terror and pain is not enemy combatants but their own caretakers. A NEW UNDERSTANDING In the three decades since I met Tom, we have learned an enormous amount not only about the impact and manifestations of trauma but also about ways to help traumatized people find their way back. Since the early 1990s brain- imaging tools have started to show us what actually happens inside the brains of traumatized people. This has proven essential to understanding the dam- age inflicted by trauma and has guided us to formulate entirely new avenues of repair. We have also begun to understand how overwhelming experiences affect our innermost sensations and our relationship to our physical reality—the core of who we are. We have learned that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body. This imprint has ongoing consequences for how the human organism manages to survive in the present. ' Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think. We have discovered that helping victims of trauma find the words to describe what has happened to them is profoundly meaningful, but usually it is not enough. The act of telling the story doesn't necessarily alter the automatic physical and hormonal responses of bodies that remain hypervigilant, prepared to be assaulted or violated at any time. For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present. Our search to understand trauma has led us to think differently not only about the struc- ture of the mind but also about the processes by which it heals.