What Happened to You? PDF by Bruce D. Perry & Oprah Winfrey

OceanofPDF.com  Begin Reading Table of Contents About the Authors Copyright Page Thank you for buying this Flatiron ebook. To receive special offers, bonus content, and info on new releases and other great...

OceanofPDF.com  Begin Reading Table of Contents About the Authors Copyright Page Thank you for buying this Flatiron ebook. To receive special offers, bonus content, and info on new releases and other great reads, sign up for our newsletters. Or visit us online at us.macmillan.com/newslettersignup For email updates on Bruce D. Perry, click here. For email updates on Oprah Winfrey, click here. OceanofPDF.com The author and publisher have provided this e-book to you for your personal use only. You may not make this e-book publicly available in any way. Copyright infringement is against the law. If you believe the copy of this e-book you are reading infringes on the author’s copyright, please notify the publisher at: us.macmillanusa.com/piracy. OceanofPDF.com  DEDICATION BRUCE D. PERRY, M.D., PH.D.: For my clan: Barbara, Grant, Jay, Emily, Maddie, Benji, Elisabeth, Katharine, Robert, and Emily In loving memory of Martha McGillis Perry OPRAH WINFREY: To the daughter girls in my life who believed they had broken wings. My hope for you is to not just fly but soar. OceanofPDF.com  A Note from the Authors This book is for anyone with a mother, father, partner, or child who may have experienced trauma. And, if you’ve ever had labels like “people pleaser,” “self-sabotager,” “disruptive,” “argumentative,” “checked out,” “can’t hold a job,” or “bad at relationships” used to describe you or your loved ones, this book is for you. Or if you simply want to better understand yourself and others, this book is for you, too. We know this reading experience will make you think and make you feel—and at times the feelings may be hard and painful. For some, the intense and sometimes disturbing content will be a challenge. For others, the concepts about the brain may be unfamiliar and initially difficult to understand. We ask for your patience and trust, with us and with yourselves. When you find the reading too challenging, stop. Put the book down for an hour or a week. It will still be there when you feel able to return to it. And when you are ready to continue exploring why “what happened to you” shapes how you think, feel, and act, welcome. You just may discover a path forward. OceanofPDF.com  INTRODUCTION “Stop your crying,” she would warn. “You better hush your mouth.” My face settled into stoic. My heart stopped racing. Biting hard into my lower lip so no words would escape me. “I do this because I love you,” she’d repeat her defense in my ear. As a young girl, I was “whupped” regularly. At the time, it was accepted practice for caregivers to use corporal punishment to discipline a child. My grandmother, Hattie Mae, embraced it. But even at three years old, I knew that what I was experiencing was wrong. One of the worst beatings I recall happened on a Sunday morning. Going to church played a major role in our lives. Just before we were to leave for service, I was sent to the well behind our house to pump water; the farmhouse where I lived with my grandparents did not have indoor plumbing. From the window, my grandmother caught a glimpse of me twirling my fingers in the water and became enraged. Though I was only daydreaming, innocently, as any child might, she was angry because this was our drinking water and I had put my fingers in it. She then asked me if I had been playing in the water and I said “no.” She bent me over and whipped me so violently, my flesh welted. Afterward, I managed to put on my white Sunday-best dress; blood began to seep through and stain the crisp fabric a deep crimson. Livid at the sight, she chastised me for getting blood on my dress, then sent me to Sunday school. In the rural South, this is how black children were raised. There wasn’t anyone I knew who wasn’t whupped.  I was beaten for the slightest reasons. Spilled water, a broken glass, the inability to keep quiet or still. I heard a black comedian once say, “The longest walk is to get your own switch.” I not only had to walk to get the switch, but, if there wasn’t one available, I had to go find one—a thin, young branch worked best, but if it was too thin I would have to braid two or three together to make it stronger. She often forced me to help her braid the switch. Sometimes the whuppings would get saved up for Saturday night when I was naked and freshly bathed. Afterwards, when I could barely stand, she would tell me to “wipe that pout” off my face and start smiling. Bury it as though it never happened. Eventually I developed a keen sense of when trouble was brewing. I recognized the shift in my grandmother’s voice or the “look” that meant I had displeased her. She was not a mean person. I believe she cared for me and wanted me to be a “good girl.” And I understood that “hushing my mouth” or silence was the only way to ensure a quick end to punishment and pain. For the next forty years, that pattern of conditioned compliance— the result of deeply rooted trauma—would define every relationship, interaction, and decision in my life. The long-term impact of being whupped—then forced to hush and even smile about it—turned me into a world-class people pleaser for most of my life. It would not have taken me half a lifetime to learn to set boundaries and say “no” with confidence had I been nurtured differently. As an adult, I am grateful to enjoy long-term, consistent, loving relationships with many people. Yet the early beatings, emotional fractures, and splintered connections that I experienced with the central figures in my early life no doubt helped develop my solitary independence. In the powerful words of the poem “Invictus,” I am the master of my fate, I am the captain of my soul. Millions of people were treated just as I was as children and grew up believing their lives were of no value. My conversations with Dr. Bruce Perry and the thousands of people who were brave enough to share their stories with me on The Oprah Winfrey Show have taught me that the effects of my treatment by those who were supposed to care for me weren’t strictly emotional. There was also a biological response. Through my work with Dr. Perry, my eyes have been opened to the fact that although I experienced abuse and trauma as a child, my brain found ways to adapt. This is where hope lives for all of us—in the unique adaptability of our miraculous brains. As Dr. Perry explains in this book, understanding how the brain reacts to stress or early trauma helps clarify how what has happened to us in the past shapes who we are, how we behave, and why we do the things we do. Through this lens we can build a renewed sense of personal self-worth and ultimately recalibrate our responses to circumstances, situations, and relationships. It is, in other words, the key to reshaping our very lives. — Oprah Winfrey One morning in 1989, I was sitting in my lab—the Laboratory of Developmental Neurosciences at the University of Chicago—looking at the results of a recent experiment, when my lab assistant poked his head into my office. “Oprah’s calling you.” “Yeah, right. Take a message.” I’d been up all night writing; the results of the experiment looked messed up. I wasn’t in the mood for a practical joke. He smirked. “No. Really. It’s somebody from Harpo.” There was no possible reason for Oprah to call me. I was a young academic child psychiatrist studying the impact of stress and trauma on development. Only a handful of people knew about my work; most of my psychiatry peers didn’t think much about the neurosciences or childhood trauma. The role of trauma as a major factor in physical and mental health was unexplored. I thought one of my friends was simply pranking me. But I took the call. “Ms. Winfrey is convening a meeting of national leaders in the area of child abuse in Washington in two weeks. We would like you to attend.” After more explanation, it became clear that the meeting would be attended by many well-known and well-established people and organizations. My work—studying the impact of trauma on the developing brain—would be lost among more politically accepted, dominant perspectives. I politely declined. Several weeks later, I received another call. “Oprah is inviting you to a daylong retreat at her farm in Indiana. There will be two other people, you, and Oprah. We want to brainstorm solutions to the issue of child abuse.” This time, with a chance to meaningfully contribute, I accepted. The dominant voice that day was Andrew Vachss, an author and attorney specializing in representing children. His pioneering work highlighted the need to track known child abusers; at that point they could move from state to state, and there was no way to keep tabs on where they were or if they were complying with restrictions to avoid children. Our 1989 meeting in Indiana led to the 1991 drafting of the National Child Protection Act to establish a national database of convicted child abusers. On December 20, 1993, after two years of advocacy that included testifying before the U.S. Senate Judiciary Committee, the “Oprah Bill” was signed into law. That day in 1989 led to many more conversations. Some took place on The Oprah Winfrey Show to discuss specific children’s stories and campaigns on the importance of early childhood and brain development. Most of our conversations, however, were in the context of the Oprah Winfrey Leadership Academy for Girls (OWLAG), which Oprah founded in South Africa in 2007. This remarkable institution was created to select, support, educate, and enrich “disadvantaged” girls with high potential. The explicit intention was to create a cadre of future leaders. Many of these girls had demonstrated resilience and high academic achievement despite a range of adversities including poverty, traumatic loss, and community or intra-family violence. Early on, the school began to act on many of the concepts we discuss in this book; today, OWLAG is becoming a model of a trauma-sensitive, developmentally aware educational setting. In 2018, I sat down with Oprah for a 60 Minutes story about “trauma- informed care.” Though only two minutes of our conversation ended up in the final segment, millions of people were watching and listening, and the excitement created in the community of professionals working in trauma was remarkable. But there is so much more to say. The enthusiasm for our conversation was in part a reflection of Oprah’s own enthusiasm for the importance of this topic. On CBS This Morning, Oprah told Gayle King that she would dance on tabletops to get people to pay attention to the impact of trauma on the developing brains of children. In a CBS News supplement to the 60 Minutes show, Oprah called it the most important story of her life. Oprah has been talking about abuse, neglect, and healing for her entire career. Her dedication to educating people about trauma-related topics has been a hallmark of her shows. Millions of people have watched Oprah listen to, connect with, console, and learn from people with experience or expertise in trauma of all kinds. She has explored the impacts of traumatic loss, maltreatment, sexual abuse, racism, misogyny, domestic violence, community violence, gender and sexual identity issues, false imprisonment, and so much more, and through this has helped us explore health, healing, post-traumatic growth, and resilience. For twenty-five years, The Oprah Winfrey Show took a deep and thoughtful look at developmental adversity, challenge, distress, stress, trauma, and resilience. She explored dissociative identity disorder in 1989; the importance of early-childhood experiences on brain development in 1997; the rights of adopted children in 2005; the impact of severe neglect in 2009; and much more. In many ways, her show paved the way for a larger, systemic awareness of these issues. Her final season included an episode featuring two hundred men, including Tyler Perry, disclosing their histories of sexual abuse. She has been and will continue to be a champion and guide for people impacted by adversity and trauma. Oprah and I have been talking about trauma, the brain, resilience, and healing for more than thirty years, and this book is, in many ways, the culmination of those talks. It uses conversation and human stories to illuminate the science that underlies it all. There are far too many aspects of development, the brain, and trauma to cover in one book, especially a book written through stories. The language and concepts used in this book translate the work of thousands of scientists, clinicians, and researchers in fields ranging from genetics to epidemiology to anthropology. It is a book for anyone and everyone. The title What Happened to You? signifies a shift in perspective that honors the power of the past to shape our current functioning. The phrase originated in the pioneering work group of Dr. Sandra Bloom, developer of the Sanctuary Model. In Dr. Bloom’s words: We [the treatment team for Sanctuary] were in a team meeting sometime around 1991 on our inpatient unit, trying to describe the change that had happened to us in recognizing and responding to the issue of trauma, especially what has become known now as childhood adversity—as a causal issue for the problems of most of the people we were treating—and Joe Foderaro, LCSW, always good at pithy observations, said, “It’s that we have changed our fundamental question from ‘What’s wrong with you?’ to ‘What happened to you?’” Oprah and I are convinced that asking the fundamental question “What happened to you?” can help each of us know a little more about how experiences—both good and bad—shape us. Our hope in sharing these stories and scientific concepts is that every reader will, in their own way, gain insights to help us all live better, more fulfilling lives. —Dr. Bruce Perry OceanofPDF.com  CHAPTER 1 MAKING SENSE OF THE WORLD More than 130 million babies are born in the world every year. Each arrives into their own unique set of social, economic, and cultural circumstances. Some are welcomed with gratitude and joy, cradled in the arms of their ecstatic parents and family. Others are more like me, experiencing rejection from a young mother who dreamed of a different life, a couple crushed by the pressures of poverty, an enraged father perpetuating a cycle of abuse. Yet whether or not they’re loved, every current and former newborn (that’s you and me) shares one profoundly important trait. Despite the myriad circumstances into which we’re born, we come into the world with an innate sense of wholeness. We don’t begin our lives by asking: Am I enough? Am I worthy? Am I deserving or lovable? Not one baby in the earliest moments of awareness asks, “Do I matter?” Their world is a place of wonder. But with their very first breaths, these tiny human beings begin trying to make sense of their surroundings. Who will nurture and care for them? What will bring comfort? And for so many little ones, life begins to take its toll, with violent eruptions by the caregiver or simply the lack of a soothing voice or a gentle touch. In our first encounters, our human experiences diverge. The most pervasive feeling I remember from my own childhood is loneliness. My mother and father were together only once, underneath an old oak tree not far from the house where my mother, Vernita, was raised in Kosciusko, Mississippi. My father, Vernon, used to tell me I would never have been born if he hadn’t been curious about what was underneath my mother’s pink poodle skirt. Nine months after that singular encounter, I arrived. From the moment I could make sense of it, I knew I was unwanted. My father didn’t even know about me until my mother sent him a birth announcement and asked for money to buy baby clothes. My grandmother Hattie Mae’s home was a place where children were seen and not heard. I have distinct memories of my grandfather shooing me away with his cane—yet no memory of him speaking directly to me. After my grandmother passed away, I was shuttled between my mother, who had moved to Milwaukee, and my father, in Nashville. Because I didn’t know either one, I struggled to develop strong roots or connections with my parents. My mother worked as a maid for fifty dollars a week in Fox Point, on the North Shore of Milwaukee, doing what she could to care for three young children. There was no time for nurturing. I was always trying not to bother her or worry her. My mother felt distant, cold to the needs of this little girl. All of the energy went to keeping her head above water, surviving. I always felt like a burden, an “extra mouth to feed.” I rarely remember feeling loved. From as early as I can remember, I knew I was on my own. What I’ve learned from talking to so many victims of traumatic events, abuse, or neglect is that after absorbing these painful experiences, the child begins to ache. A deep longing to feel needed, validated, and valued begins to take hold. As these children grow, they lack the ability to set a standard for what they deserve. And if that lack is not addressed, what often follows is a complicated, frustrating pattern of self-sabotage, violence, promiscuity, or addiction. This is where the work begins—the work to excavate the roots that were put down long before we had the words to articulate what was happening to us. Dr. Perry has helped open my eyes to the ways in which powerful, frightening, or isolating sensory experiences that last mere seconds or are endured for years can remain locked deep in the brain. Yet as our brains develop, constantly absorbing new experiences while continuing to make sense of the world around us, every moment builds upon all the moments that came before. I have always felt the truth of the saying that the acorn contains the oak. And through my work with Dr. Perry, I know this to be true, too: If we want to understand the oak, it’s back to the acorn we must go. — Oprah Early in our relationship, I remember Oprah saying, “You’re the guy who sees everything through the lens of the brain. Do you think about the brain all the time?” The short answer is, almost. I think about the brain a lot. I was trained as a neuroscientist and have been studying the brain and stress- response systems since I was in college. I’m also a psychiatrist, a field I pursued after my training in the neurosciences. I’ve found that a “brain- aware” perspective helps me when I’m trying to understand people. Being a child psychiatrist, I’m often asked about troubling behaviors. Why is that child acting like a baby? Can’t he act his age? How could a mother stand by and watch her boyfriend beat her child? Why would someone ever abuse a child? What is wrong with that child? That mother? That boyfriend? Over the years, I’ve found that seemingly senseless behavior makes sense once you look at what is behind it. And since the brain is the part of us that allows us to think, feel, and act, whenever I’m trying to understand someone, I wonder about that person’s brain. Why did they do that? What would make them act that way? Something happened that influenced how their brain works. The first time I was able to use this neuroscience lens to understand behavior, I was a young psychiatrist, still training. I was working with an elderly man, Mike Roseman—a smart, funny, kind man. Mike was a veteran of the Korean War and had seen lots of combat. He had classic PTSD (post- traumatic stress disorder) symptoms, which we’ll talk about in a deeper way later; he suffered with anxiety, sleep difficulties, depression, and episodic flashbacks in which he literally felt as if he was in combat. He had resorted to self-medicating with alcohol and struggled with binge drinking. This, of course, contributed to work and family conflicts, and ultimately led to divorce and forced retirement. We had been working together for about a year, and Mike had been doing pretty well managing his drinking, but his other symptoms persisted. One day he called, very upset. “Doc, can I come in and see you today? It’s important. And Sally wants to come.” Sally was a retired teacher Mike had been dating; he’d talked a lot in previous sessions about not wanting to “blow this one.” Sensing the urgency, I agreed. Later that afternoon, they came into my office and sat next to each other on the couch. They were holding hands. Sally gently whispered in his ear; Mike looked shamed, and it was clear she was trying to reassure him. They looked like nervous teenagers. He started. “Can you explain PTSD to her? You know, why I’m all messed up.” He started to tear up. “What’s wrong with me? Korea was over thirty years ago.” Sally moved to hold him. I felt myself floundering—could I really explain PTSD?—so I stalled. “If I may ask: Why now, Mike? Did something happen?” “We were going out last night. Had a nice dinner and we were walking downtown on our way to the movies. And suddenly I was in the street, between parked cars, on my belly with my hands over my head, terrified. I thought we were being shot at. I was pretty confused, I guess. At some point, I realized that a motorcycle had backfired. Sounded like gunfire. The knees on my suit were torn. I was sweaty, my heart was racing. I was so embarrassed. Felt like I was jumping out of my skin. I just wanted to go home and get drunk.” Sally said, “One minute we were arm in arm, the next he is back in a foxhole in Korea, screaming. I tried to get down and help him, but he just pushed me away. He hit me.” She paused. “It seems like it lasted for ten minutes, but I think it was only a couple of minutes. Tell me how to help him.” She turned to look at Mike. “I’m not giving up on you.” “Tell her what’s wrong with me,” he pleaded. This was 1985. Research on PTSD was still very preliminary, and I was a twenty-nine-year-old inexperienced psychiatrist-in-training; I didn’t know squat. “Listen, I don’t know if I have any answers here,” I said. “But I do know that Mike was not trying to hurt you.” “I know that.” Sally looked at me like I was an idiot—the idiot I actually was. But while I didn’t know much about clinical work, I did know a lot about the brain, memory, and the stress response. I thought about Mike jumping for cover in the street, not as a clinician but as a neuroscientist. What was going on in his brain when that motorcycle backfired? I started to look at a clinical problem through the lens of the brain. “I think part of the problem is that many years ago, in Korea, Mike’s brain adapted to continuous threat—his body and brain became oversensitive and overreactive to any threat-related signals from the world. Back then, to stay alive, his brain made a connection—basically a specialized form of memory—between the sounds of gunfire and shelling and the need to activate an extreme survival response.” I paused. “Does that make sense?” Sally nodded. “He is jumpy.” “Mike, I’ve seen you flinch and startle in my office many times when a door slams or a cart rattles too loud in the hallway. You’re always scanning the room, too. Any little shift in activity, sound, light draws your attention.” “If you didn’t keep your head down,” Mike said, “you were dead. If you weren’t vigilant at night, you were dead. If you fell asleep, you were dead.” He stared into space, unblinking. After a moment of silence, he sighed. “I hate the Fourth of July. And New Year’s. The fireworks make me jump out of my skin. Even if I know there will be fireworks, I still jump—my heart feels like it will burst out of my chest. I hate it. I can’t sleep for a week after that.” “Right. So that original adaptive and protective memory is still there. It hasn’t gone away.” “But he doesn’t need it anymore,” Sally said. “It’s actually making his life miserable. Can’t he just unlearn it?” “That is a great question,” I said. “The tricky part is that not all of these combat-related memories are in parts of the brain Mike can consciously control. Let me try to explain this a bit.” I pulled out a piece of paper and drew an upside-down triangle and three lines dividing it into four parts. It was the first time I’d represented the brain that way. Thirty-five years later, we still use this basic model to help teach about the brain, stress, and trauma. “Let’s look at the basic organization of the brain. It’s like a four-layered cake. At the top is the cortex, the most uniquely human part of our brain.” I started labeling my drawing with different brain-mediated functions, as in the illustration, opposite. As I did, I explained: “The systems at the top are responsible for speech and language, thinking, planning; our values and beliefs are stored there. And, very important for you, this is the part of the brain that can ‘tell time.’ When the cortex is ‘online’ and active, we can think about the past and look forward to the future. We know which things are in our past and which things are present, yes?” Mike and Sally nodded. “Okay. Now look at the bottom of the brain—the brainstem. This part of the brain controls less complex, mostly regulatory, functions like body- temperature regulation, breathing, heart rate, and so forth. But there are no networks in the bottom part that think or tell time. Sometimes we refer to this part of the brain as the reptilian brain, so think of what a lizard can do —they don’t plan much, or think; they mostly live in the moment and react. But we humans, thanks to the top part of our brain—the cortex—can invent, create, plan, and tell time.” I looked at them to make sure they were tracking with me before continuing. “Input from all of our senses—vision, hearing, touch, smell—first comes into our brain in the lower areas. None of our sensory input goes directly to the cortex; everything first connects to lower parts of the brain.” They nodded. “Once the signal comes into the brainstem”—here I directed their attention to the bottom of the triangle—“it is processed. Basically, the incoming signal is matched against previously stored experiences. In this case, the matching process connected the motorcycle backfire with gunfire —remember that combat-related memory? And since your brainstem can’t tell time, or know that many years have passed, it activates the stress response and you have a full-blown threat response. You feel and act as if you are under attack. Your brainstem can’t say, ‘Hey, don’t get so stirred up, Korea was thirty years ago. That sound was simply a motorcycle backfiring.’” Figure 1  A MODEL OF THE BRAIN HIERARCHICAL ORGANIZATION OF THE HUMAN BRAIN The brain can be divided into four interconnected areas: brainstem, diencephalon, limbic, and cortex. The structural and functional complexity increases from the lower, simpler areas of the brainstem up to the cortex. The cortex mediates the most uniquely “human” functions such as speech and language, abstract cognition, and the capacity to reflect on the past and envision the future. I watched this sink in. “Now, when the signal finally gets up to the cortex, the cortex can figure out what’s really going on. But one of the first things that happens when you activate the stress response is that systems in the higher parts of the brain, including our ability to ‘tell time,’ get shut down. So the information about the motorcycle backfire did ultimately get to the cortex, but it took a while. And until it did, you were back in Korea and then confused. It took you all night to calm down, right?”  “I didn’t sleep at all.” Mike looked exhausted but relieved. “So I’m not crazy?” “No. Your brain is doing exactly what you would expect it to do considering what you lived through. But what was once adaptive has become maladaptive. What kept you alive in Korea is killing you back home. We have to figure out how to help your stress-response systems become less reactive and supersensitive.” That, of course, is not the end of Mike’s story, but the understanding of what was “underneath” his confusing behavior was very comforting for him and Sally. For me, it started a much more active process of integrating principles from the neurosciences into clinical practice. It illuminated how “evocative cues”—basically any sensory input, like a sight, sound, smell, taste, or touch—can activate a traumatic memory. In Mike’s case, the motorcycle backfire evoked the complex memory of combat. And it was one of the first examples I shared with Oprah when we began to discuss trauma. Oprah: When I hear Mr. Roseman’s story, the first thing I notice is that he felt flawed; he even asks, “What is wrong with me?” But you focused on “What happened to me?” rather than “What’s wrong with me?”—which is exactly the shift we’re trying to help others make. His story also helped me really understand what you mean when you talk about the “sequential” organization of the brain. Dr. Perry: All experience is processed from the bottom up, meaning, to get to the top, “smart” part of our brain, we have to go through the lower, not- so-smart part. This sequential processing means that the most primitive, reactive part of our brain is the first part to interpret and act on the information coming in from our senses. Bottom line: Our brain is organized to act and feel before we think. This is also how our brain develops— sequentially, from the bottom up. The developing infant acts and feels, and these actions and feelings help organize how they will begin to think. Oprah: For years, you’ve been telling me that the earliest experiences have the biggest impact because that is when the brain is most rapidly growing. Dr. Perry: Not only is “What happened to you?” the key question if you want to understand someone, it is the key question if you want to understand the brain. In other words, your personal history—the people and places in your life—influences your brain’s development. The result is that each of our brains is unique. Our life experiences shape the way key systems in our brain organize and function. So each of us sees and understands the world in a unique way. The example of Mr. Roseman involves traumatic experiences that took place when he was twenty-four years old. If these experiences changed the brain of a twenty-four-year-old, imagine the impact of trauma on the brain of an infant or toddler—how much more pervasive the effects would be. Starting in the womb, the developing brain begins to store parts of our life experience. Fetal brain development can be influenced by a host of factors including mother’s stress; drug, alcohol, and nicotine intake; diet; and patterns of activity. During the first nine months, development is explosive, at times reaching a rate of twenty thousand new neurons “born” each second. (In comparison, an adult may, on a good day, create seven hundred new neurons.) By birth, the newborn has 86 billion neurons; these will continue to grow and connect to create complex networks that allow the newborn to begin making sense of their world. This is all extremely complex and not fully understood by researchers, but there are a few basic principles that will be helpful throughout our conversations about how this relates to trauma. Our external senses—sight, sound, smell, taste, and touch—monitor what is going on outside of our body. To do this, they rely on the sensory organs—eyes, ears, nose, and skin. When these are stimulated by light, sound, smell, or touch, specialized neurons send a signal into the brain. We also have sensory systems that tell us what is going on inside our body. This is called interoception, and it creates our sense of, for instance, being thirsty, hungry, or short of breath. All the sensory inputs from the outside world and our inside world give continuous feedback to the brain so that the proper systems can be activated to keep us healthy and safe. If we’re thirsty, we seek water; if we’re hungry, we seek food; if we sense danger, we mobilize our stress-response systems.  The brain categorizes every bit of sensory input and sends it “up the triangle” to other parts of the brain to integrate and process it further. This creates an increasingly rich and detailed version of any experience, as various inputs become linked based on how they’re sorted. For example, the brain sends some visual input to the same areas it sends auditory (sound), tactile (touch), and olfactory (smell) sensations that come in at exactly the same time. These different sensations—the sights, sounds, smells, and movements of the same experience—then become connected. This is the beginning of making sense of the world. As your brain starts to create the complex memories that store these connections, your personal catalog of experiences is being created. As we grow up, we are all trying to make sense of what’s happening around us. What does that sound mean? What does it mean when someone rubs my back? What does that expression on his face mean? What else happens when that scent is present? For one child, eye contact means, “I care for you; I’m interested in you.” For another it may mean, “I’m about to yell at you.” Moment by moment in early life, our developing brain sorts and stores our personal experiences, making our personal “codebook” that helps us interpret the world. Each of us creates a unique worldview shaped by our life’s experiences. Imagine, for a moment, the dramatic changes in the sensory world of a newborn. Their world, once warm, rhythmic, and dark, becomes, at the moment of birth, an overwhelming sensory bath of images, sounds, temperature shifts, and exposure to air. The brain is bombarded by new patterns of sensory input. And because so much of the world is new when you’re a baby, that’s when your brain is most rapidly and actively making these new connections. The experiences in the first years of life are disproportionately powerful in shaping how your brain organizes. Oprah: One of the most important things I’ve learned from your research is that young children absorb so much more than we realize. The younger you are, the more sensitive you are to your emotional climate. People feel like they can curse in front of young children. They believe they can be violent in front of young children. I’ve done hundreds of shows where mothers said, “Well, when he gets older, I’ll leave the abusive father”—thinking, My child’s too young to understand, when, in fact, it’s exactly the opposite. Dr. Perry: Yes, it’s exactly the opposite. The younger you are, the more you depend upon your caregivers—parents and other adults—to help you interpret the world. In some ways, the young child experiences the world through the filters of these adults. While a very young child may not understand the words used in language, they do sense the nonverbal parts of communication, like tone of voice. They can feel the tension and hostility in angry speech, and the exhaustion and despair of depressed language. And because the brain is growing so rapidly in the first years of life and creating thousands upon thousands of associations about how the world works, these early experiences have more impact on the infant and young child. For example, when children have abusive fathers, their brains begin to connect men with threat, anger, and fear. And this worldview gets built in— men are dangerous, threatening, they will hurt you and the people you love. If that is your ingrained view of the world, imagine what happens when you have a male teacher or coach. Imagine how you will view a new, healthy, non-abusive man in your mother’s life. Oprah: And when you haven’t developed the words or ability to identify what you see or feel, you’re just operating on vibration. And the vibration in the house is … this is bad. Dr. Perry: That vibration, as you describe it, equates to the emotional tone of the environment. Oprah: Yes, I believe every environment has a tone. If you were to walk into any home as a stranger, not speaking the language, you could absolutely feel whether this is a place where people are loved. Just as you can sense when something’s off. You may not know what it is, but something feels off. Dr. Perry: And in the same way, you could walk into a preschool and say, “Wow, this is a great environment.” You can feel the climate, the emotional tone. And you could go to a different classroom in the same school and say, “Whoa, what’s going on here?” It’s so powerful. There are parts of our brain that are very, very sensitive to nonverbal relational cues. And in our society, this is an underappreciated aspect of the way human beings work. We tend to be a very verbal society—written and spoken words are important—but the majority of communication is actually nonverbal. Oprah: You teach that when you experience trauma in the first years of life, meaning from birth through age two—before you’ve developed the ability to explain the event—it can have a deeper impact on your brain than when you actually do have the words to explain it. I think about children who are molested when they are so young that they don’t have the language to process what has happened. The experience locks into the brain in a way it wouldn’t if the child could express with words what happened. Dr. Perry: What you’re describing here is a form of memory. Let’s turn back to the upside-down triangle I drew for Mr. Roseman. Each biological system in our body has some way to change in response to experience; in a sense, then, that change is a record of past experiences— or, basically, memory. Neurons are exquisitely sensitive to experience, and neural networks in every part of the brain can make memory. Remembering names, phone numbers, and where you left your keys is a function of the neural networks of the cortex. But we also have emotional memories: A song can elicit a feeling, an association with an experience that took place years ago. The smell of roasted turkey or freshly baked bread may elicit a warm sense of belonging, or a melancholy sense of a lost past. These feelings arise from associations stored in the neural networks of the limbic and other brain regions. And there are motor-vestibular memories—curling up in the fetal position is essentially an act of remembering—stored in even lower networks in the brain. But traumatic experience can create complex memory traces that involve all regions of the brain.  As we’ve mentioned already, the brain develops sequentially, from the bottom up and the inside out, from the basic functions of the brainstem to the complex achievements of the cortex. Each brain area has the capacity to create memory—to change in response to experience and to store those changes in its particular neural networks. In a young child, the cortex is not yet fully developed; in children younger than three, the neural networks are not mature enough to create what’s called linear narrative memory (in other words, a who, what, when, and where memory). However, in lower areas of the brain, other neural networks are processing—and changing as a result of—our earliest experiences. Associations, or memories, are being created in these lower networks, and this has a huge impact on how trauma is stored in the brains of the very young. If a child experiences abuse, their brain may make an association between the features of the abuser or the circumstances of the abuse—hair color, tone of voice, the music playing in the background—and a sense of fear. The complex and confusing associations can influence behaviors for years; later in life, for example, being served in a restaurant by a brown- haired man who hovers over you while he takes your order may elicit a panic attack. But because there is no firmly embedded cognitive recollection—no linear narrative memory—the panic is often experienced and interpreted as random, independent of any previous experience. A lifelong set of beliefs and behaviors can emerge when trauma is experienced at a young age. In one of the most serious manifestations, early sexual abuse can poison intimacy, even if the person has no actual recollection of specific instances of abuse. Oprah: Two hundred and seventeen episodes of The Oprah Winfrey Show focused on sexual abuse, and I saw a profound through-line for most victims, including myself. When you’ve been groomed to be compliant, confrontation in any form is uncomfortable because you were never taught that you have the right to say no; in fact, you were taught that you can’t say no. The sense that you aren’t deserving enough to set your own boundaries has been stolen from you. Many people react by burying their feelings of “no” and becoming people pleasers. I fall in that category. For years, I would say yes to things I knew I really did not want to do, or avoid difficult conversations because I could not live with the discomfort of speaking up for myself. I’ve known other victims of trauma who sabotage situations until someone else says no for them—meaning their relationship ends, a friendship becomes toxic, or they lose a job. This is what I hear you saying when you talk about people who poison intimacy. But the extreme experiences we’ve talked about so far—sexual molestation, child abuse, war—aren’t the only experiences that can cause trauma. The term can actually apply to a vast spectrum of life events. For me, there is no better example of this than the story of Kris and Daisy, who first appeared on The Oprah Winfrey Show in an episode about children of divorce. At the time, Kris was seven years old. Daisy, his sister, was eleven. Not only had they endured the trauma of their parents’ divorce, but it had been several years since they’d had any contact with their mother. Kris was only four when he’d last seen her, and his longing was heartbreaking. He believed that if he could buy a ring for his mother with the money he’d saved, she would come back to him. That broke me wide open. Daisy’s hurt, on the other hand, presented itself as anger. “You’re not supposed to have a boyfriend when you’re married,” she told me, referring to her mother. The woman who was supposed to love her unconditionally and be her greatest teacher had disappeared from her life. Daisy described it as “unbearable.” On the show, rabbi and family therapist M. Gary Neuman told me that for most children, divorce is really like a death. He explained that children don’t see their parents as separate people who came together. They see one parent unit within one family unit. So even if divorce is what’s best for the family overall, the children feel pieces of themselves being torn away. And if one parent is no longer available, or suddenly introduces a new relationship to the dynamic before the child can develop trust, it impacts the areas of the brain involved in shaping self-worth. The sense of self informs every relationship or decision we make as we move through life. And when children don’t feel respected by the decisions of their parents, their beliefs about how they are valued are crushed. Kris and Daisy were the first children I’d ever heard speak such truth about the trauma of their parents’ breaking up. Some people believe that the younger the child, the easier a new relationship is to absorb; Kris and Daisy’s story confirmed for me that this isn’t true. I know your research suggests the same. Explain to me from a neurological perspective what happens to a child’s brain in that situation. Dr. Perry: When a new relationship enters the picture, two things happen. First, the child—and this is true even of babies—begins asking internally, “Who is this person, and what is this?” Second, they feel the shift of their parent’s attention away from them and onto this other person. So you can start to see how destabilizing this is, even without any hostile, aggressive, or abusive stuff going on. Oprah: Meaning even when the relationships are relatively healthy. Dr. Perry: Right. Even if it’s a really nice, kind, respectful person entering the child’s life, it takes a long time for the child to make sense of the shift and get back to a calm, regulated state. As we’ll talk about later, anything new will activate our stress-response systems. Our default response to novelty is “Uh-oh. What is this?” And until the new thing is proven safe and positive, it will be categorized as a potential threat. For most people, the unknown is one of the major causes of feeling anxious or overwhelmed. And, of course, it’s worse if there is conflict in the relationship. Let’s say a young boy is yelled at by his mother’s new boyfriend. This experience is processed and stored in the cortex as a narrative—who, what, when, where—memory: “On Monday, the boyfriend came to the house and yelled at me.” But it’s also stored deeper in the brain. When the boyfriend was yelling, the boy’s stress response was activated. The key regulatory systems governed by the lower parts of his brain sped up his heart, increased his muscle tone, and sent signals to his body to prepare for fight or flight. Fear shuts down thinking and amps up feeling, and the boy was afraid. And as his brain is trying to make sense of the whole experience, it’s also making a trauma memory. Later on, when this boy is exposed to a trigger or evocative cue that reminds his brain of that traumatic experience, his heart rate will go up. His body posture will change. The cocktail of hormones in his body will shift. The point is that our body’s core regulatory systems can be altered by traumatic experiences. A child exposed to unpredictable or extreme stress will become what we call dysregulated. Oprah: And living in a traumatizing environment causes the child to be continually dysregulated. Dr. Perry: Yes. For instance, if a child sees repeated verbal or emotional or physical abuse of their parent, or experiences abuse directly from a parent’s partner, their brain makes connections between all the attributes of the abuser and threat. These associations can influence how the child experiences and interprets relationships as they grow up. Oprah: And that forms what you call a “personal catalog—or the codebook” that shapes the lens through which we perceive the world. Dr. Perry: Absolutely. These early-life associations are incredibly powerful and pervasive. Once, I was working as a consultant to a residential treatment center, where there were about one hundred boys, roughly seven to seventeen years old. All of these children were “state kids”—wards of the state following removal from their family due to abuse or neglect. After struggling in foster care, these boys had been placed in this residential program. They lived in a dorm-like setting, and most of them attended an on-site school. One boy I worked with was a fourteen-year-old named Samuel. When he was seven, Child Protective Services (CPS) had moved him and his four younger siblings from their home. They had all been neglected, and Samuel had been caring for and protecting the others; when his father drank, Sam was the target of his most violent outbursts. When the children were removed, the younger ones went to a separate foster home. Sam was distraught; he kept running away from foster homes to find them. He’d been in twelve foster homes—and twelve schools—before being placed in the residential setting at age eleven. One of the first things we did was reconnect him with his siblings, setting up weekly calls and monthly visits. Knowing they were safe and loved settled him. Only then could the hard work of healing really start. For the next three years, Sam made great progress. His social skills improved; he was developing better self-control when frustrated or disappointed; he became more hopeful and focused on the future. Though the chaos in his life had left him three grades behind in school, he was catching up to the point where he was moved up to a new classroom. Sam’s new teacher was energetic, well-liked, experienced—and male. During the first week in the new classroom, Sam had three major outbursts; two of them, directed at the teacher, were so aggressive and violent that Sam had to be physically restrained. This was an extreme intervention for this program and highly unusual behavior for Sam. Unfortunately, it kept happening. The staff was confused and frustrated. Sam was sullen and ashamed. I sat down with the teacher to review each event, and neither he nor I could see any obvious trigger for the explosive outbursts. I observed Sam’s classroom and saw no inappropriate or potentially provocative behavior by the teacher. Yet Sam was clearly agitated anytime the teacher talked with him or tried to give him any help with his work. Proximity was the only possible trigger I saw; the closer the teacher was, the worse Sam’s agitation. Over time, the teacher began avoiding any interaction—no eye contact, no verbal encouragement, no smiling. He was disengaging emotionally as well as physically. It was clear these two didn’t like each other. One day when I was talking with Sam about this, his only explanation was, “He hates me. Nothing I do is right.” Our session was interrupted by a staff member who reminded Sam that it was almost time for his visit with his father. These visits had to be supervised, and the caseworker had not arrived, so I volunteered to go with Sam. We went to a conference room, and I sat in the corner waiting for Sam’s father to show up. Sam sat at the conference room table stacking checkers. Waiting. His father was late, again. Finally, the door opened, and the father came in and sat down across from Sam. They exchanged awkward greetings and set up to play checkers. For the next ten minutes, maybe ten words were exchanged as they played. Neither looked at the other. The tension was palpable. My mind drifted as they played. I found myself thinking about my own father. Fishing trips up in Canada, north of Flin Flon. His waking me from a warm slumber at 5 a.m. to get out among the walleye. His putting on his red-checked flannel hunting shirt that had his scent—his special mix of cigar, sweat, and Old Spice. Such a warm and reassuring scent. I was swept with an intense feeling of being safe and loved. As I surfaced from my daydream, the smell of Old Spice still hung in the room. Could it be? I walked over to the table and bent down between Sam and his father. “How’s the game going?” The father said, “He’s winning.” I could smell alcohol on his breath and the Old Spice he’d slathered on to hide it. He was supposed to come to see Sam sober. After the visit ended, I went to see the teacher. He was in his classroom preparing for the next day. “This may seem a bit strange,” I said, “but what kind of deodorant do you use?” “Old Spice. Why?” I took out a paper and pencil and drew the upside-down triangle model of the brain, and we talked for a minute or two about memory, associations, and triggers. I told him that I thought the scent of Old Spice was an evocative cue for Sam (just like one of Mr. Roseman’s evocative cues was explosive sounds). The teacher agreed to change to a scentless deodorant. Later that afternoon, I asked Sam to sit down with me, and I explained what I thought was making him so uncomfortable and angry with the teacher. I showed Sam the same upside-down triangle brain drawing, and we talked about how our brain makes sense of the world by connecting sights and sounds and smells that “co-occur.” He nodded; it made sense to him. He gave me other examples of things he knew pushed his buttons: when someone yelled, he wanted to run and hide; when a bigger person bullied a smaller person, he wanted to attack. I asked if he would be willing to sit down with the teacher and see if we could have a redo on their relationship. Both Sam and the teacher agreed to give each other another chance. Over the next year, their relationship grew strong, and Sam ended up being a model student in that classroom. Sam’s story illustrates so much about how the brain stores memory. Both Sam and I had experiences earlier in life where our brains made memories connected to the smell of Old Spice. My associations elicited positive feelings; his elicited distress and fear. As we make our way through the world, countless sounds, smells, and images can tap into memories we created earlier in life. These memories may be full-blown recollections of a specific event, or they may be fragments—a feeling, a sense of déjà vu, an impression. When we meet someone, we form a first impression (“He seems like a really nice guy”), frequently with no apparent information on which to base it. This is because attributes of the person evoke in us something we’ve previously categorized as familiar and positive. The opposite can happen (“This guy is a complete jerk”) if some attribute taps into a previous negative experience. Our brain catalogs vast amounts of input from our family, community, and culture, along with what is presented to us in the media. As it makes sense of what it’s stored, it begins to form a worldview. If we later meet someone with characteristics unlike what we’ve cataloged, our default response is to be wary, defensive. In turn, if our brains are filled with associations based upon media-driven biases about ideal body type, or racial or cultural stereotypes, for example, we will exhibit implicit biases (and maybe overt bias). So many phenomena of everyday life are directly linked to this process of the brain making sense of the world by creating associations and making memories. This is why asking “What happened to you?” is so important in understanding what’s going on with you now. OceanofPDF.com  CHAPTER 2 SEEKING BALANCE How much do you think about your heart? Since before you were even born, that miraculous machine has been steadily pumping the energy of life throughout your body. Day in, day out, at least 115,000 beats each day, with the sole purpose of keeping you alive. But beyond the complex physical task of delivering essential nutrients to every cell, tissue, and organ, your heart’s pulse also regulates your emotional energy. A strong, even pace can bring a sense of calm. A rapid staccato can panic even the healthiest person. There was a time in my late forties when I noticed a change, a rapid fluttering, in my own heart. I immediately started thinking worst-case scenario. One night I awoke with my heart beating so intensely, I thought for the first time in my life that I was about to die. It took six months before I understood what was happening. A book I found lying on a table outside the studio where we taped The Oprah Winfrey Show noted that heart palpitations can be part of menopause. A doctor confirmed that this was true and that my body was indeed undergoing menopausal changes, and I can’t tell you how relieved I felt. Relieved and awed. Because for me, those direct messages from my heart were one of the most powerful connections I’d ever made with my unique biosystem. They were proof of what I already believed: that my body is always speaking to me. The same is true for you. From birth, your heart is constantly sending messages about the state of your well-being. It’s intimately attuned to the slightest shifts in your physical and emotional health, and when it sends out a warning, every part of you feels the effect. Ever since those episodes with my heart, I’ve felt deep gratitude for this ever-vigilant internal alarm. In times of stress, its changes in cadence have been a gift. But as I have learned from Dr. Perry, remaining in a constant state of high alert can have devastating effects on your overall physical and emotional health. The correlation between long-term stress and conditions like anxiety, depression, stroke, heart disease, and diabetes is real. I was in my twenties when I was first challenged, in a big way, to regulate my own stress. I’d taken a job as a reporter and was working hundred-hour weeks. I wanted to be a team player, but I could feel myself becoming increasingly out of sync. As I explained earlier, traumatic events in my childhood, including an uprooted family, sexual abuse, and regular beatings, had conditioned me to be a skilled people pleaser, even if it meant completely depleting my own energy. And so, when I felt the stress indicators that my body was sending, I ignored them, choosing instead to soothe myself with the drug that was most easily accessible: food. The more out of rhythm my life became, the more I sought relief to silence the signals. I was tuned in enough to know that I was betraying myself. I knew that I had only a certain amount of energy, and I knew that it needed to be conserved and restored. But it would take decades for me to understand how to live within my own rhythms. Now when I begin to feel overwhelmed, I pull back. I have learned to say no. When I’m around someone who drains me, I put up a barrier—a nonphysical wall that keeps that person’s negative energy away. I’ve also created a sacred personal space, blocking out Sundays as a time of renewal, allowing myself to be with myself, allowing myself simply to be. When this time is interrupted or threatened by someone who invades my state of calm, I become irritable, anxiety-prone, and distressed about making decisions—not the person I want to be in the world. The quickest and most consistent way for me to get back to my own rhythm is to walk in nature. Just focusing on my breath, my steady heartbeat, the stillness of a tree, or the intricacy of a leaf can center me in the wholeness of all things. Music, laughter, dancing (even a party for one), knitting, cooking— finding what naturally soothes you not only regulates your heart and mind, it helps you stay open to the goodness in you and in the world. — Oprah Oprah: I remember walking on the OWLAG campus with you, watching the girls dance, sing, and laugh together as they moved from one class to the next. You had been working with the students there for over ten years, and as we looked on, you said something like, “That will help them learn.” We ended up talking about why rhythm is so important. Dr. Perry: Rhythm is essential to a healthy body and a healthy mind. Every person in the world can probably think of something rhythmic that makes them feel better: walking, swimming, music, dance, the sound of waves breaking on a beach. … Oprah: It’s why we rock babies when they cry. We’re trying to help them find their own rhythm to help calm them down. Dr. Perry: Exactly, and that will help us calm down, as well. The emotions of people around us are contagious. When our baby is upset, it can make us upset. So we go to the baby and hold her and walk with her. We start with a rhythm that is soothing to us, and if that doesn’t work, we slowly shift to a pattern that is regulating for the baby. The baby’s response to our efforts shapes the style of the rhythmic soothing we use. As we grow up, we find our own set of regulating rhythms and activities. For some of us, it is walking. For others, it’s doing needlework or riding a bike. Everyone has their go-to options when they feel out of sync, anxious, or frustrated. The common element is rhythm. Rhythm is regulating. Oprah: People use the word wellness to mean overall health or balance among mind, body, spirit. But you talk about regulation. Help me understand what you mean by that. Dr. Perry: Regulation is also about being in balance. We have many different systems that are continuously monitoring our body and the outside world to make sure we’re safe and in balance—that we have enough food, water, oxygen. When we’re regulated, these systems have what they need.  Stress is what occurs when a demand or challenge takes us out of balance—away from our regulated “set points.” When we get out of balance, we become dysregulated and feel discomfort or distress. When we get back into balance, we feel better. Relief of distress—getting back into balance—activates the reward networks in the brain. We feel pleasure when we get back into balance—from cold to warm, thirsty to quenched, hungry to satiated. Oprah: And regulation is more than a biological concept. In all areas of our lives, we are seeking what we need to be stabilized, balanced, and regulated. Dr. Perry: Yes. Balance is the core of health. We feel and function best when our body’s systems are in balance, and when we’re in balance with friends, family, community, and nature. Oprah: And what’s really important for parents to realize is what you just said—that learning healthy self-regulation actually begins in infancy. When babies cry, they’re either hungry or thirsty or tired, or their diaper needs changing or they need to be touched. And since they can’t feed themselves or change their own diaper, crying is their way to get themselves back into balance—to get their caregiver to do what has to be done in order for them to get back into balance. The problem is when their caregiver doesn’t respond. Rather than being put back in balance—regulated—the baby will get more upset. Dr. Perry: Yes. If I get hungry, I get up and make myself a sandwich—I self-regulate. But as you said, the infant has to rely on adults to help her with this. Caregiving adults provide external regulation. Over time, these responsive adults help the child’s brain begin to build self-regulating capabilities. And as we’ve mentioned, one of the most powerful tools we use to help regulate a distressed infant is rhythm. Oprah: Why is that? Dr. Perry: All life is rhythmic. The rhythms of the natural world are embedded in our biological systems. This begins in the womb, when the mother’s beating heart creates rhythmic sound, pressure, and vibrations that are sensed by the developing fetus and provide constant rhythmic input to the organizing brain. These experiences create powerful associations— essentially, memories—that connect rhythms of roughly sixty to eighty beats per minute (bpm) to regulation. Sixty to eighty bpm is the average resting heart rate for an adult; it’s the rhythm the fetus sensed, and it equates to being in balance, to being warm, full, quenched, safe. After birth, rhythms at these frequencies can comfort and soothe, whereas the loss of rhythm, or high, variable, and unpredictable patterns of sensory input, becomes associated with threat. When we rock the distressed baby, the rhythmic movement activates this memory of safety. The infant feels more in balance and calms down. Furthermore, by rocking the baby while also feeding, warming, and loving them, the caring adults strengthen the primary associations between rhythm and regulation. These loving interactions begin to expand the complex “memory” of regulation by mixing in human contact. The caregiver’s smell, touch, smile, and voice also become connected with regulation—with safety. The roots of health are rhythm and regulation. When you mix in attentive, responsive, and nurturing caregiving, the roots and trunk of our brain’s Tree of Regulation are being organized (see Figure 2). Oprah: So, when you are raised in a nurturing, supportive, caring environment and you cry and someone responds to your needs, you are being regulated. Ultimately, as you grow up with this loving attention, what you describe as the Tree of Regulation grows—and these networks in your brain allow you to regulate yourself and connect to people in healthy relationships. Dr. Perry: Exactly. And this is so important that it’s worth a closer look. First, as we’ve been discussing, we have important neural networks involved in regulation—including our stress-response systems. Second, we have neural networks that are involved in forming and maintaining relationships. Finally, we have neural networks that are involved in “reward”; when these are activated, they give us pleasure. When these three systems begin to wire together, they create our foundational memories; these are the reason that we feel regulated and rewarded when we get signals of acceptance or warmth from another person. A person’s capacity to connect, to be regulating and regulated, to reward and be rewarded, is the glue that keeps families and communities together. Oprah: Regulation, relationship, and reward. Dr. Perry: Yes. When the attentive and responsive adult comes to the crying infant, two very important things happen. The baby feels the pleasure of being regulated after being distressed—and also experiences the sight, smell, touch, sound, and movement of human interaction. The loving sensations provided by the adult caregiver start to become associated with pleasure. In thousands of moments, when the caregivers respond to the needs of the infant, the brain is connecting relationship to reward and regulation. And so, when you are an attentive, attuned, and responsive caregiver to these little ones, you’re literally weaving together this powerful three-part association—you’re building a healthy root system for the Tree of Regulation. Furthermore, as we talked about earlier, these bonding experiences create the infant’s worldview about humans. A consistent, nurturing caregiver builds an internal view that people are safe, predictable, and caring. Oprah: The humans coming to regulate me are not bad. When I need something, it will work out. People are safe and supportive. Dr. Perry: Yes, and that’s a remarkable and powerful worldview. We learn that a connection with another person can be rewarding and regulating. It pulls us to engage with our teachers, coaches, classmates. It usually leads to more and more positive human interactions that add to our internal catalog of experience. The brain is a meaning-making machine, always trying to make sense of the world. If our view of the world is that people are good, then we will anticipate good things from people. We project that expectation in our interactions with others and thereby actually elicit good from them. Our internal view of the world becomes a self-fulfilling prophecy; we project what we expect, and that helps elicit what we expect. Many years ago, I was at Chicago’s O’Hare airport in the winter on my way to an academic conference. It was snowing, and all the flights were delayed. The gate area was filled with frustrated people, including an older gentleman sitting next to me. He was wearing a very expensive suit and a Rolex watch, and his frustration was clear. Each time the gate agent announced a further delay, he would mutter with fury and angrily snap his newspaper before reading some more. Figure 2 TREE OF REGULATION  Note: HPA = Hypothalamic-Pituitary-Adrenal Axis; ANS = Autonomic Nervous System; CRNs = Core Regulatory Networks The Tree of Regulation is comprised of a set of neural networks our body uses to help us process and respond to stress. We tend to use the word stress in negative ways, but stress is merely a demand on one or more of our body’s many physiological systems. Hunger, thirst, cold, working out, a promotion at work: All are stressors, and stress is an essential and positive part of normal development; it’s a key element in learning, mastering new skills, and building resilience. The key factor in determining whether stress is positive or destructive is the pattern of stress, as shown in Figure 3. We have a set of core regulatory networks (CRNs), or neural systems, originating in the lower parts of the brain and spreading throughout the whole brain, that work together to keep us regulated in the face of various stressors.  Collectively, the branches of this Tree of Regulation direct or influence all functions of the brain (like thinking and feeling) and the body (impacting your heart, stomach, lungs, pancreas, and more). They are trying to keep everything in equilibrium, everything regulated, everything in balance. I was watching a tired-looking young couple take turns following their daughter, a toddler, as she explored around the gate. For hours, as the stranded passengers grew more and more irritated, the toddler kept smiling, exploring and touching everything she saw. At one point, when the gate agent came out and announced another delay, the man next to me burst from his seat, almost ran to the agent, and loudly demanded to see her supervisor. “I’m a gold medallion traveler, and I know people on the Board. I’m due in Cleveland for a very important meeting.…” The whole gate fell silent as his rant continued. The poor gate agent simply looked out the window, pointed to the heavy snow falling, and said, “I’m sorry, sir. We are doing our best, but we can’t control the weather.” The man huffed back to his seat. Now, in my working model of the world, rude, entitled men treating people poorly are jerks, but when I glanced over at the little girl, her head was cocked as if she were trying to figure out why everyone had gotten quiet when this man talked. Her working model of the world was that people are good. So whatever else this man might be, he was good, too. She walked right over and stood before him; she put her sticky little hands on his knees and smiled. He frowned and snapped his paper up to read, right in front of her face. My worldview was reinforced: He’s even mean to little children? Super jerk. The little girl paused. Then, clearly thinking that this was a game— because people are good, right?—she smiled and ripped the paper down, beaming at who she thought would be her new playmate. Oh, man, I thought. This is bad. But I was wrong. And she was right. She smiled her big smile. And, shaking his head in defeat, he smiled back. Her “goodness projected” was contagious. She drew the best from this man, and her worldview was reinforced. For the next thirty minutes, the two of them played together as her parents looked on; he even got down on his hands and knees—expensive suit be damned—to give her a horsey ride around the dirty, crowded gate. She elicited what she projected, thanks to an internalized view of the world that came from thousands of loving moments when her parents, family, and caregivers were present, attentive, and responsive in loving ways. Oprah: But what happens when a baby doesn’t get those positive, nurturing responses? Say, if a mom is on her own with no help, or depressed, or in a violent relationship? She may really want to be a loving, responsive parent, but is that possible under those circumstances? Dr. Perry: This is one of the central problems in our society; we have too many parents caring for children with inadequate supports. The result is what you would expect. An overwhelmed, exhausted, dysregulated parent will have a hard time regulating a child consistently and predictably. This can impact the child in two really important ways. First, it affects the development of the child’s stress-response systems (see Figure 3). If the hungry, cold, scared infant is inconsistently responded to—and regulated—by the overwhelmed caregiver, this creates an inconsistent, prolonged, and unpredictable activation of the child’s stress- response systems. The result is a sensitization of these important systems. In prolonged cases of trauma, the CRNs of the Tree of Regulation change and adapt so that they can better cope with the current challenge. The system works hard to keep you in balance, but it can be difficult and exhausting. And in these long-term cases, even when the challenge passes, the change in these systems persists. The hypervigilance of a boy living with domestic violence scanning his home for any sign of threat is very adaptive; in a classroom, this can prevent the child from paying attention to the teacher and result in the child being labeled with attention deficit disorder (ADHD), which is maladaptive. The second major problem has to do with that process of creating connections about relationships. If, while the infant is creating her working model of the world, the caregiver responds in unpredictable ways, or is episodically rough, frustrated, cold, or absent, the child begins to create a different sort of worldview. We had a project working with a preschool where we were observing student-teacher interactions. In one of the classrooms, there was a young, enthusiastic, and very nurturing teacher. At the beginning of the year, this teacher warmly greeted each child, gave them a hug and a big smile. All during the day, this teacher interacted with the children in very attentive ways. We noticed that one little girl avoided this teacher’s physical affection and never made eye contact. When the teacher hugged her, she simply stood still and didn’t reciprocate. Eventually we learned that this child had a very overwhelmed, depressed mother and that no other adults were in the household. As time went by, the teacher continued to be warm and effusive with the other children, but week by week, the positive overtures to this withdrawn, sad girl decreased. You can imagine that this girl’s worldview was I’m not that important; you can’t really trust people. About a month into the school year, the class was doing an activity when the little girl raised her hand for help; it was the first time she’d ever reached out that way. She held her hand high. Waved it. But the teacher was fully engaged with a group of children at another table and didn’t notice. The teacher was laughing and smiling with the other children. The little girl watched for a few moments, then slowly lowered her hand. For the rest of the year, she never asked for help again. After the project was over, we showed the video clip to the teacher, who started to cry. She felt terrible guilt. There was no intention to ignore this girl, but we all require some reciprocal social feedback to stay engaged. The little girl’s working model of the world—I don’t matter—projected into the classroom and became a self-fulfilling prophecy. We elicit from the world what we project into the world; but what you project is based upon what happened to you as a child. Figure 3 PATTERNS OF STRESS ACTIVATION  The long-term effects of stress are determined by the pattern of stress activation. When the stress-response systems are activated in unpredictable or extreme or prolonged ways, the systems becomes overactive and overly reactive—in other words, sensitized. Over time, this can lead to functional vulnerability, and since the stress-response systems collectively reach all parts of the brain and body, a cascade of risk in emotional, social, mental, and physical health occurs. In contrast, predictable, moderate, and controllable activation of the stress- response systems, such as that seen with developmentally appropriate challenges in education, sport, music, and so forth, can lead to a stronger, more flexible stress-response capability— i.e., resilience. Oprah: So, because this little girl may not have had her basic needs met earlier in her life, because her mother was overwhelmed, alone, exhausted, and depressed, and therefore unable to be “present, attentive, attuned, and responsive,” as you say, the child is out of balance. And if this pattern of care develops into outright neglect—where the fundamental needs are ignored for longer and longer periods of time, or those cries for help go unmet or are responded to with anger or punishment—the child is living with constant distress. In either situation, she is out of balance. Dr. Perry: Absolutely. And probably the most important aspect of this is the pattern of stress activation. If the parent is consistent, predictable, and nurturing, the stress-response systems become resilient. If the stress- response systems are activated in prolonged ways or chaotic ways, as in cases of abuse or neglect, they become sensitized and dysfunctional. Though we’re generally not aware of it, we are continually sensing and processing information from the outside world; based upon this input, our brain and body respond in ways that help keep us connected, alive, and thriving. When we are pushed out of equilibrium—out of balance—we have a set of stress-response systems that will be activated to help us. Most people are familiar with the term “fight or flight.” This refers to a set of responses that can kick in when we are afraid. Your brain will focus your attention on the potential threat, shutting down unnecessary mental processes (like reflecting on the meaning of life or daydreaming about an upcoming vacation). Your sense of time collapses to the moment. Your heart rate goes up, sending blood to your muscles in preparation, potentially, for fleeing or fighting. Adrenaline pumps through your body. This response is activating your body. As we’ll talk more about later, this “arousal” response is not the only way we can respond to a threat. Imagine a situation where you are too small to win a fight and unable to run away. In this case, the brain and the rest of the body prepare for injury. Your heart rate goes down. You release your body’s own painkiller—opioids. You disengage from the external world and psychologically flee into your inner world. Time seems to slow. You may feel like you are in a movie, or floating and watching things happen to you. This is all part of another adaptive capability, called dissociation. For babies and very young children, dissociation is a very common adaptive strategy; fighting or fleeing won’t protect you, but “disappearing” might. You learn to escape into your inner world. You dissociate. And over time, your capacity to retreat to that inner world—safe, free, in control—increases. A key part of that sensitized ability to dissociate is to be a people pleaser. You comply with what others want. You find yourself doing things to avoid conflict, to ensure that the other person in the interaction is pleased, as well as gravitating toward various regulating, but dissociative, activities. Finding balance can be an exhausting challenge for anyone with trauma- altered stress-response systems. The search to avoid the pain of distress can lead to extreme, ultimately destructive, methods of regulation. Oprah: One of the most raw conversations I’ve had about the struggle to find relief from emotional imbalance was with the British actor and comedian Russell Brand. At the time, he’d been sober for eleven years, but he’d recently published a powerful essay about how he continued to think about heroin nearly every day. “Drugs and alcohol are not my problem,” he wrote. “Reality is my problem, drugs and alcohol are my solution.” Russell told me that as a child, he felt alienated from the people around him. He was raised by a single mother with very little money, and he described himself as confused, lonely, and at a loss as to how to handle his feelings. There were points in his life when he could “not distinguish between where he ended and the pain began,” and he developed dangerous habits including compulsive eating, an “infatuation” with pornography, and eventually a devastating addiction to drugs. “I couldn’t cope with being me,” Russell said. Yet even during some of his darkest moments, he said he often felt gratitude for the respite drugs provided from what he called an overwhelming “internal storm.” On the sixteenth anniversary of his sobriety, Russell went on social media to credit his in-patient recovery treatment, support groups, and mentors. He said, “I have freedom now, and you can have freedom too.” The spiritual teacher Gary Zukav has said, “When you find an addiction, do not be ashamed. Be joyful. You have found something that you have come to this Earth to heal. When you confront and heal an addiction, you are doing the deepest spiritual work that you can do on this Earth.” All this is by way of saying that we’ve known for years that there is a correlation between drug addiction and trauma, but the death toll just keeps rising. Dr. Perry, through your work with trauma victims, you’ve found that most people are not taking drugs for the reasons that we think. It’s not about self-indulgence and pleasure-seeking, or even a method to escape life in general, as much as it is about avoiding the pain and distress of dysregulation. True? Dr. Perry: So often when we ask, “What happened?” we find a history of developmental trauma. Most people with “developmental adversity” are chronically dysregulated—they tend to be wound up, anxious. Sometimes they feel like they are jumping out of their skin—or, as Russell Brand described it so well, the internal storm. As we will talk more about in a bit, their CRNs are sensitized. If you grow up in a household or community characterized by unpredictability, chaos, and ongoing threat, you will very likely end up with altered stress-response systems. This is especially true if the abuse, chaos, or exposure to violence took place in the home, and the very adults who were supposed to be nurturing and protecting you were the source of the pain, chaos, fear, or abuse. Remember what we said about the pattern of stress activation: Even in the absence of major traumatic events, unpredictable stress and the lack of control that goes with it are enough to make our stress-response systems sensitized—overactive and overly reactive—creating the internal storm. And also remember that humans are emotionally “contagious”; we sense the distress of others. Imagine a child in a home with a frustrated, angry father who has no job prospects, is disrespected in the community due to his status or skin color, and comes home feeling impotent, defeated. This parent’s internal storm becomes the home’s storm. His chaos becomes the home’s chaos. He may use alcohol or a drug to manage his distress. But a drug-using parent, a drunk, overwhelmed, frustrated parent is going to create a climate of fear for their children. As much as they may want to protect the children from their distress, and as much as they love their children, the mess is made. The children grow up internalizing this; they are incubated in terror.  And as these children get older and are introduced to drugs or alcohol themselves, they may discover that they can feel a quiet they have never experienced; the pleasure that comes from the relief of distress becomes a powerful reward. Remember: Relief of distress gives pleasure. They are relaxed for the first time in their lives. The pull to go back and use again is very powerful, though it’s affected by how dysregulated you are, and by the nature and strength of the other sources of reward in your life. Every day we “fill our reward bucket” with various sources of reward—and not every day is the same (see Figure 4). Some days will be rich with friends and family; other days you may fill your “reward bucket” by volunteering at a local food kitchen. And some days, we are left empty, unfulfilled. Many of us found it harder to “fill up” during the COVID-19 pandemic; people reported more anxiety and depression, and many people used some of the less healthy forms of reward to fill that void. Figure 4 FILLING OUR REWARD BUCKET  Activation of key neural networks in the brain can produce the sense of pleasure or reward. These reward circuits can be activated in multiple ways, including relief of distress (e.g., using Alcohol to self-medicate or Rhythm to regulate the anxiety produced by a stress- response system that’s been altered by trauma); positive human interactions (Relational); direct activation of the reward systems using various drugs of abuse such as cocaine or heroin (Drugs); eating Sweet-Salty-Fatty Foods (SSF foods); and behaviors consistent with your values or beliefs (Beliefs). Each day we need to fill our “reward bucket.” The darker dashed line is a minimal level of reward that we need to feel adequately regulated and rewarded; if our daily set of rewards falls below this, we feel distressed. If we get above the upper, black-dotted line, we feel fulfilled and regulated. Each of us does this in a somewhat individualized way. Many of us have opportunities for healthy rewards: lots of positive human interactions through work, worship, or volunteering that are consistent with our values and beliefs, for example (A). But a lack of strong relationships and connection can make an individual more vulnerable to overuse of other, less healthy forms of reward (B). A healthy combination of rewards (e.g., lots of positive human interactions, doing work consistent with your values, integrating healthy rhythm and sexuality into your day, staying regulated in healthy ways) can help decrease the pull toward any single, unhealthy form of reward such as substance use or overeating. The challenge with activating our reward circuits is that the pleasure fades. The feeling of reward is short-lived. Think how long the pleasure of eating a potato chip lasts. A few seconds. Then you want another. Same with a hit of nicotine from a cigarette. Or even the smile of a loved one. It feels so good in the moment, and we can recall it and get a little pleasure, but the intense sense of reward fades. So each day we are pulled to refill our reward bucket. The healthiest way to do this is through relationships. Connectedness regulates and rewards us. Yet when substance abuse is involved, it can push loved ones away. And many interventions used to deal with substance abuse are punitive and increase distress. The pull to use gets stronger. Disconnection, marginalization, demonizing, and punishing only make the problems of substance abuse worse. The cycle of dysregulation, self- medication, relational disruption, lack of reward leads to more substance abuse. And the spiral continues. But here’s what’s interesting about drug use: For people who are pretty well-regulated, whose basic needs have been met, who have other healthy forms of reward, taking a drug will have some impact, but the pull to come back and use again and again is not as powerful. It may be a pleasurable feeling, but you’re not necessarily going to become addicted. Addiction is complex. But I believe that many people who struggle with drug and alcohol abuse are actually trying to self-medicate due to their developmental histories of adversity and trauma. Oprah: It’s interesting to hear you say that, because I know lots of people who take drugs for their anxiety, whereas I have found medications like that just put me to sleep. Because my internal baseline is already so calm, when I take something that’s supposed to just relax me, I doze off. Dr. Perry: Right. You probably have friends who take the same amount that puts you to sleep. Oprah: In some cases, they’re taking twice as much. And I’m thinking, How is everybody not just asleep? But if your baseline stress response is already elevated, you need more anxiety medication to get below your base. So even though people may not appear to be in a state of high alert or anxiety, they are biologically revved up. Dr. Perry: Yes, and the drug soothes that. But when it comes to finding solutions to substance abuse and freedom from it, we will never truly solve the problem until we begin to focus on what happened to them. Oprah: Yes. What happened to you? Always the question to ask first. Dr. Perry: This is why a developmentally informed, trauma-aware perspective is so important for all of our systems impacted by or dealing with substance use and dependence—education, mental health, health, law enforcement, juvenile and criminal justice, family courts. It is impossible to find any part of our society where this is not an issue. We have such good intentions, and we have good people, and we’re spending a lot of money, but we’re ineffective because we are not understanding the underlying mechanisms that make someone vulnerable to chronic substance use. Oprah: We need to understand that victims of trauma are more prone to all forms of addiction because their baseline of stress is different. Dr. Perry: It comes back to dysregulation. There’s always a pull to regulate, to seek comfort, to fill that reward bucket. But it turns out that the most powerful form of reward is relational. Positive interactions with people are rewarding and regulating. Without connection to people who care for you, spend time with you, and support you, it is almost impossible to step away from any form of unhealthy reward and regulation. This includes alcohol overuse, drug overuse, eating too much sweet and salty food, porn, cutting, or spending hours and hours on video games. Connectedness counters the pull of addictive behaviors. It is the key. OceanofPDF.com  CHAPTER 3 HOW WE WERE LOVED I sat in the darkened room watching the mother, Gloria, and her three-year- old daughter, Tilly, through a one-way mirror. They were doing great together. Gloria was tracking with Tilly’s cues, much more in sync than in previous visits. Both appeared more comfortable with each other. Over the two years I had been watching their visits together, there had been so much positive change. On my left was Tilly’s new Child Protective Services (CPS) caseworker, her fifth over the last two years. On my right was Mama P, the child’s foster mother. I’d known Mama P for years. She was a loving woman with an endless reserve of positive energy. She had fostered dozens of children; each was special to her, each loved. Mama P probably taught me more about trauma and healing than anyone. Gloria had been removed from her family when she was six. She struggled as she grew up in the child protective system, bouncing from foster home to foster home, school to school, community to community. Gloria had multiple complex social, emotional, and physical health problems related to her many traumatic experiences. Unfortunately, she’d been misunderstood by everyone: her therapists, foster caretakers, caseworkers, judges, teachers. Twenty years ago, awareness of the impact of trauma wasn’t very high. By age eighteen, when Gloria “aged out of the system,” she was using a variety of drugs to self-medicate her pain. On her nineteenth birthday, she was eight months pregnant and homeless. By her twentieth, she had an infant daughter, no support, no family, no work. Ultimately, the child protective system removed Tilly. Fortunately, Tilly was sent straight to Mama P. Over the next two years, Mama P helped both Gloria and Tilly. She was attentive and nurturing, creating a safe and stable home for Tilly. And she invited Gloria to be present and involved in Tilly’s life as long as she wasn’t using or drinking. Mama P realized that Gloria needed as much safe and stable nurturing as Tilly; she realized that Gloria was a young, unloved child in a woman’s body. In the beginning, Gloria didn’t engage much. But after nine months or so, she accepted our offer to get clinical help for her trauma-related problems.  By now, both Tilly and Gloria had grown up significantly. It was getting close to the time when Gloria would be able to care for Tilly on her own. But for that to happen, CPS had to make that recommendation to the court. This observed visit was part of the CPS “reunification” plan. We three sat silently, watching Tilly and Gloria. After about ten minutes of play, Gloria reached into her coat pocket and pulled out some candy. I could feel the CPS caseworker stiffen. “She is not supposed to bring candy to these sessions.” On my other side, I could feel Mama P make herself bigger in response to the caseworker’s words. I quietly put my hand on Mama P’s, trying to reassure her. She was very protective of both Gloria and Tilly. Tilly was prediabetic. In the first year of treatment, we’d noticed that Gloria, with so few relationship tools, used candy to make Tilly “happy.” We came to understand that this was the primary way in which Gloria’s foster caregivers had managed her when she was young; getting candy was the closest Gloria got to being loved. Our brains develop as a reflection of the world we grow up with. You love others the way you’ve been loved. Gloria was merely showing love to her daughter the best way she knew. The caseworker continued, “She knows that she is not supposed to do that. This child is prediabetic. This is abusive.” “No,” I said. “It’s sugar-free candy.” Clearly, this caseworker, new to Tilly and likely dealing with sixty other cases, had not read the most recent reports. “How do you know that?” “I gave them to her before the session.” I could feel Mama smiling. A year earlier, in a team meeting where we were trying to figure out the best way to balance Tilly’s prediabetic condition with Gloria’s impulse to use candy to show love, one of my clinical team members wanted to admonish Gloria. He suggested searching her before visits and prohibiting contact if she snuck candy to Tilly. Mama P disagreed. “That poor mother is doing the best she can. Let her give her daughter some candy. That is all she knows. You will not make her a better parent by punishing or shaming her. If we want her to be a more loving parent, we need to be more loving to her.”  So instead of admonishing Gloria, we simply had her switch to sugar- free candy, and taught her about nutrition and diabetes. And, of course, Mama P made sure that Gloria and Tilly both got lots of love. We explained this to the new caseworker, and together we created a transitional plan for reunification with lots of support for both Gloria and Tilly. Gloria got her GED and went to community college to study nursing. Mama P stayed active in their little family. Rather than undermine a mother doing the best she could, we kept showing Gloria and Tilly love, and how to love. One of the most remarkable properties of our brain is its capacity to change and adapt to our individual world. Neurons and neural networks actually make physical changes when stimulated; this is called neuroplasticity. The way they become stimulated is through our particular experiences: The brain changes in a “use dependent” way. The neural networks involved in piano playing, for example, will make changes when activated by a child practicing her piano. These experience-dependent changes translate into better piano playing. This aspect of neuroplasticity— repetition leads to change—is well known and is why practice in sports, arts, and academics can lead to improvement. A key principle of neuroplasticity is specificity. In order to change any part of the brain, that specific part of the brain must be activated. If you want to learn to play the piano, you can’t simply read about piano playing, or watch and listen to YouTube clips of other people playing piano. You must put your hands on the keys and play; you have to stimulate the parts of the brain involved in piano playing in order to change them. This principle of “specificity” applies to all brain-mediated functions, including the capacity to love. If you have never been loved, the neural networks that allow humans to love will be undeveloped, as in Gloria’s case. The good news is that with use, with practice, these capabilities can emerge. Given love, the unloved can become loving. — Dr. Perry Oprah: If I were to count the number of people I’ve interviewed—and believe me, I’ve tried—it would be over fifty thousand. And in nearly forty years of conversations, beginning with my early years working in Nashville, through The Oprah Winfrey Show and up to today, one common denominator has never changed: All of us want to know that what we do, what we say, and who we are matters. Like clockwork, whether it’s the President of the United States, Beyoncé in all her Beyoncé-ness, a mother sharing a painful secret, or a convicted criminal in search of forgiveness, at the end of any interview, the person sitting across from me asks, “How did I do?” as they scan my face for a reaction. “Was I okay?” they always ask. The longing to be accepted and affirmed in their truth is the same for everyone. And beyond science, I know it boils down to this: how you were loved. Dr. Perry: Yes, belonging and being loved are core to the human experience. We are a social species; we are meant to be in community— emotionally, socially, and physically interconnected with others. If you look at the fundamental organization and functioning of the human body, including the brain, you will see that so much of it is intended to help us create, maintain, and manage social interactions. We are relational creatures. And the capacity to be connected in meaningful and healthy ways is shaped by our earliest relationships. Love, and loving caregiving, is the foundation of our development. What happened to you as an infant has a profound impact on this capacity to love and be loved. Oprah: The word love gets thrown around a lot. But really, the key is how you were given care; how your specific needs were met. I’m thinking of what we talked about earlier with regulation. The baby will be hungry or cold—out of balance. And when the baby cries, expressing need, the caregiver comes and “regulates” the child. Dr. Perry: The caregiver coming to me