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63 pages 2 hours read

Bruce D. Perry, Oprah Winfrey

What Happened To You?: Conversations on Trauma, Resilience, and Healing

Nonfiction | Book | Adult | Published in 2021

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Themes

The Biological Context of Trauma

From the outset, the book focuses on grounding the reader in the biological context of human experience. The very first chapter discusses the human brain, explaining how it is structured and organized. With help of an illustration of an upside-down triangle segmented into four parts, Perry explains how the brain increases in complexity of function from the bottom to the top: The brainstem, responsible for automatic, regulatory functions; the diencephalon, which works with states of arousal; the limbic system, where one’s emotions are seated, as is the reward-response system; and the cortex, the uniquely human layer responsible for all higher-order cognitive processes, from language and memory to values, beliefs, and the ability to think about time. Perry explains the extreme malleability of the human cortex, allowing it to be shaped and reshaped by experience. This feature, the neuroplasticity of the human brain, is what has allowed generations of human beings to not only learn and accumulate skills, but also pass them down to future generations in a continuing sociocultural evolution.

Despite the cortex being the smartest part of the human brain, it is the last to develop; this is a function of its sequential nature. The brain developed from bottom to top, just as it also receives and processes information from bottom to top. Thus, in an infant, it is the brainstem that is mostly at play in their processing of and engagement with the world. The infant reacts based on feeling, and thinking develops much later. This also implies two things: Firstly, that the brainstem and the way it functions is key to survival for the human being, as it works on instinct that helps keep a vulnerable, young human alive; secondly, that the early experiences of a child’s life have profound impact on shaping their worldview, as the associations formed in the brainstem during this time are strong, deep, and create implicit memories. These memories form implicit biases that influence how one receives, processes, and categorizes information even later in life, thus shaping one’s worldview. For instance, if in early childhood one has been treated with kindness and love, then one grows up with the sense that people are generally good and kind, developing a worldview that has one operating from a default of trust, even with strangers.

In the case of negative and traumatic experiences, however, the opposite happens—associations are formed that can become maladaptive later in life. Especially because the initial years of a child’s life sees them heavily dependent on sensory input to form initial memories, simple smells, sounds, and visual cues can come to serve as strongly evocative cues of emotions and reactions. This is illustrated in Samuel’s example, where he visibly and violently reacts to the smell of Old Spice, as his physically abusive father used this cologne. Furthermore, because the brainstem is incapable of telling time, when it receives an evocative cue that is related to a stored memory, it reacts to the cue as if the present experience is the same as the past—the information does not reach the cortex immediately, where it can be processed as two different incidents separated by time. Thus, one sees Mike reacting to the sound of a backfire as if he were back in Korea and being shot at once again.

Thus, one sees an interaction between one’s biology and one’s experiences in shaping thoughts, behavior, and personality. Furthermore, in the case of trauma, the path for healing, too, is outlined in this same biology. The same malleability of the brain that allowed it to be shaped to respond to stress can also learn new ways of coping if given the right experiences and nurturing. The latter is important, and Perry continually stresses the significant role that relationship and connectedness can play in healing, which also connects to another theme: Love and Relationships. With respect to the brain and biology, Perry references the “Tree of Regulation,” an interconnected system of neural networks that help one adequately respond to and regulate in the face of stress. He suggests that three things ought to be wired together for the “Tree” to be healthy and strong: rhythm, regulation, and reward. The soothing effects of rhythm, from the baby being rocked in the mother’s womb to being soothed in a parent’s arms, to finding stress relief in activities such as dance, exercise, and music, prove its regulatory effects. When a parent responds to an infant’s dysregulated cry by picking it up and rocking it, the trio of rhythm, regulation, and reward become intertwined: the baby is regulated through rhythm, and the relief from distress is rewarding. Furthermore, it ties in the aspect of relationship: the caregiver’s consistent response allows the baby to understand that relationship is regulating and rewarding. Perry stresses this, quoting that the most rewarding regulator is, ultimately, relationship.

Besides the biological underpinnings in trauma and healing with respect to neural networks and stress repossess, Perry also highlights that stress and trauma can impact one’s biology in other ways. The more apparent or understood impacts of stress and trauma are on mental health, manifesting in conditions such as anxiety, depression, or PTSD; however, stress and trauma can have impacts on an individual’s physical health as well. Tyra’s example is used to illustrate this point, where her stress-response to the evocative cue of siren sounds led her blood glucose to become erratic, on account of the adrenaline being released in her system. As a diabetic, this had an impact on her physical health, leading to her hospitalization and difficulty administering the right dose of insulin to help regulate her levels.

Ultimately, by constantly underscoring the relationship between one’s biology and one’s experiences, Perry attempts to dispel the idea that the experience and effects of trauma are purely a psychological experience. While he acknowledges the subjective nature of trauma, which is what makes it difficult to define the term, he also illustrates how trauma can have tangible, observable, and physical effects on one’s brain and biology. This highlights the importance of having not just mental health professionals, but also clinicians, social institutions, and public health spaces constantly asking the question: What happened to you?

Love and Relationships

One of the most important ideas that comes through in the book is the centrality of love to the experience of being human. Winfrey’s observation that every interviewee wanted to know how they did as the interview concluded demonstrates the universal desire to be seen and appreciated, pointing to the common need to be loved. This idea is seconded by Perry, who asserts that the act of loving and caregiving forms the foundation of biological development in human beings. Humans are a social species, and love is the relational glue that has ensured the survival of the species.

In addition to, or perhaps because of this, Perry constantly reiterates that when it comes to restoring balance or healing from trauma, relationships are key. The concept of the “Tree of Regulation” suggests as much: In a healthy individual, there forms an interlinked set of neural networks which see rhythm, regulation, and reward wired together in the context of relationship. The lack of love and caregiving at a crucial point in an individual’s life, namely the initial years, can be extremely damaging. Perry describes how children who have had a stable and happy first two months of life but are thrust into years of adversity after, are still able to cope better than children who have had tumultuous initial months followed by years of calm. This indicates the importance of love to the very foundation of human biology, a fact reiterated by one of Perry’s patients, James. Although he had never been directly abused, the inconsistent and neglectful upbringing he experienced in his early childhood ensured that James never developed the tools to be able to cope and adjust later in life, even with the help of therapeutic intervention.

In keeping with this, Perry points out how the single largest predictor of mental health is not childhood adversity or access to a therapist, but in fact one’s relationship and connectedness. Having a web of invested and caring others in one’s life can not only prove effective buffering against a variety of stressors but can actively aid healing even after the experience of trauma. Thomas provides a contrast to James, as he presented with similar behavioral issues and a history of physical abuse, but made leaps and strides in his progress due to a network of loving adults around him. When comparing Thomas’s experience with James’s, the vitalness of love becomes apparent. The lack of love and relationships can be as toxic and damaging as trauma, and the presence of it can boost healing.

In this context, Perry suggests that a host of conditions that exist in today’s world with respect to mental health, specifically anxiety and the difficulty of healing from trauma, are a function of relational poverty in the modern world. There are increasingly fewer opportunities for interactions that allow one to form real connections and relationships, which contributes to lowering one’s threshold for stress—an idea further explored in a third theme of Revisiting Ancient Wisdom. Ultimately, the book constantly reiterates the need for creating and maintaining a network of loving and supportive relationships in every individual’s life, for this helps ensure a sense of balance, regulation, and healthy reward, and provides a buffer against trauma and its effects.

Revisiting Ancient Wisdom

The contrast between the modern world and ancient wisdom is an idea explored in some detail in the book. Specifically in the context of trauma, Perry suggests that the way the modern world is organized is unhelpful to the healthy development of robust stress-response systems and prohibitive to effective healing from trauma.

To illustrate this, he refers to how most traditional or Indigenous communities were built on four common pillars with respect to balance and healing: a connection to the clan and to the natural world; regulation through some form of rhythm (song, dance, percussion); a collection of stories and beliefs that helped make sense of even senseless trauma; and on occasion, the consumption of a hallucinogenic or similar drugs under supervision of an elder. The modern world lays emphasis on the latter two—cognitive-behavioral approaches and medication—while almost completely neglecting the first two, i.e., the importance of relationship and community, and rhythmic activities, to promote regulation.

Beyond neglecting the importance of community, the organization of the modern world seems to actively contribute to fragmentation and isolation. Humans once lived in small communities of less than one hundred people; one’s world was small, but strong and rich in connections and developmental diversity. The urban setting sees the opposite of this, i.e., a larger, but more superficial network of people, by way of humans living in large, crowded cities and being able to travel and communicate across vast distances owing to advancements in technology. However, this vast population that one interacts with daily are mostly strangers; the number of close relationships and the interactions they yield in an individual’s daily life has greatly reduced. The vast, perpetual, and novel sensory input that is a product of modern living—from constantly being surrounded by people, most of whom are strangers, to the input from devices and screens—means that the brain is continually monitoring the environment for threat. This, without the counterbalancing effect of sufficient close relationships in one’s life, automatically leads to a sensitization of the stress response systems.

In contrast, Perry recalls his time with the Māori community, and some of the information he learned from them. The Māori do not have any conceptual separations of categories such as education, healthcare, public policy, and so on. There is a wholeness to their thinking and being, and they view all of their lived experience as interconnected. Relatedly, the Māori understand all pain, irrespective of its presentation or expression, to arise from the same core problem: fragmentation, disconnection, and desynchrony. In keeping with this, the Māori community emphasizes whanaungatanga—the idea of relationship and kinship as central to healing.

This is in keeping with Perry’s constant assertion throughout the book, that relationship and connectedness are of extreme significance in regulation and balance, also connecting to the theme of Love and Relationships. Perry further demonstrates the effectiveness of the same in recovering from trauma through retelling Timothy’s story, the young boy being raised by an exhausted single mother, both of whom found healing and progress once they discovered and established community. The conclusion of the book sees Perry making an appeal for a return to ancient wisdom, particularly in the context of increasing connectedness with an awareness of the impact of one’s past. This is what will help move the individual and society from a place of trauma, to “typical,” to finally arriving at post-traumatic wisdom.

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