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Anxiety and Breathing

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Published on: December 26, 2012

Only Anxiety is Forbidden

So far we have observed that confronting interpersonal human aggression at close range is, perhaps, “the universal human phobia,” which can result in a greater degree of psychological trauma than any other possible human experience. But the greatest trauma may occur afterwards, as a result of the midbrain’s “hijacking” of the forebrain.

In an extreme fear situation the midbrain reaches up and takes hold of the forebrain. Afterwards there appears to be an immediate, neural “shortcut” to the midbrain which mobilizes the body for survival in response to any “cue” associated with the traumatic incident. Increased heart rate, respiration, and perspiration and a host of other physiological responses will occur for even the slightest of reasons and sometimes for no discernible reason whatsoever. This can be thought of as a powerful form of associative or Pavlovian conditioning in which a host of neutral stimuli have now become conditioned stimuli which will touch off a powerful, “one trial learning,” conditioned response in the autonomic nervous system.

Time can be a valuable survival mechanism. When our ancestors first heard a lion’s roar they had to think, if even for a millisecond, “Oh, so THAT is a lion, I’d better run.” Subsequently the processing of that stimulus (i.e., the lion’s roar) would bypass the forebrain and essentially go straight from ears to their feet, saving milliseconds and enhancing their survival in the process. Indeed, not just the lion’s roar, but the lion’s smell, the nature of the terrain, that spot in the jungle, and that time of day might also all be processed. Subsequently, individuals might not even know what has set them off, but something caused anxiety, made the hair stand up on the back of their necks, and caused them to slink away quietly. Soldiers in combat soon learn (if they are lucky to survive long enough) to react reflexively to the earliest hint of the sound of incoming artillery, and even to distinguish between kinds of artillery and the variety of responses required for survival, all without ever engaging the forebrain.

But for those of us who do not live on a battlefield, or hunt in the jungle, and with the exception of minor experiences like hot stoves, the powerful associations involved in these “one-trial learning” experiences can be extraordinarily distressing. I would venture to claim that nothing distresses healthy human beings more than to think that they are losing control of their minds. The midbrain’s “hijacking,” “hardwiring,” or “bypassing” of the forebrain can subsequently result in erratic, uncontrollable physiological reactivity. Even under the best of conditions this can sometimes continue for up to a year after a traumatic situation. When this occurs victims can become greatly distressed by the sense that they are losing control of their minds. But the “best of conditions” seldom occur naturally. Usually the physiological reactivity that occurs will cause them to dread further incidents, because they “know what will happen.” Thus their fear and physiological reactivity become enmeshed in a vicious cycle, a self-fulfilling prophecy in which anxiety creates fear and that fear creates more anxiety and so on. Very quickly the individual begins to manifest a powerful PTSD response.

In an attempt to assert control, or to avoid this reactivity, victims will attempt to (as outlined in the DSM-IV): repress memories; avoid thoughts, places, or activities that remind them of the incident; hypercontrol their emotions; limit their expressions of emotion and affection; and cease activities that once caused them emotional or physical pleasure. This intense effort to hypercontrol their own minds and to avoid this fearful physiological reactivity will result in sleep problems because what they deny in the day will confront them in their dreams. They will experience hypervigilance and exaggerated startle reactions. Their emotions, forbidden to trickle out in a steady flow, will come out in bursts of rage and anger.

But it doesn’t have to be this way. If, at the very beginning, we can teach subjects to control their autonomic, physiological arousal, then they can nip this whole process in the bud, stopping the vicious cycle of fear and anxiety before it consumes them. “But,” we say, “it is called an ‘autonomic’ response because it is ‘automatic.’” Yes, but the bridge between the somatic and autonomic nervous system is breathing, and an increasing body of research and law enforcement experience indicates that if we teach the victim to control their breathing then they can control their physiological arousal. (This is based on information and feedback gained from training over 20,000 law enforcement personnel in this technique over the last three years.) The breathing technique that is being taught to SWAT teams, police departments, Green Beret battalions, and other elite forces around the world (sometimes referred to as “autogenic breathing”) consists simply of a deep, belly breath: breath in for a four-count, hold for a four-count, breath out for a four-count, hold for a four-count, and repeat three times.

It is not original with me, but I have been teaching this to mental health practitioners, military, law enforcement, and to my psychology classes for over five years now. In one case a young student whom I had not seen for several years came up to me in the supermarket with a tale he was burning to tell. “I was in a traffic accident,” he said. “My car flipped over, and I was trapped in the car, with one leg broken and one lung crushed.”

“What did you do?” I asked.

“I began to panic,” he said. “And then I remembered what you taught us: ‘In, two, three, four; hold, two, three, four; out, two, three, four; hold, two, three, four’ and I began to calm down.”

“Then what?”

“What else could I do? I turned the radio on and waited for someone to come get me. And they did. They pried open the car and pulled me out and said that if I had panicked and tried to tear myself out I might have killed myself.”

In one clinical situation a police officer who was suffering from a heart attack sat in the intensive care unit and demonstrated to his doctor how he could cut his heart rate in half using this technique. Around the world this technique is being embraced by military and law enforcement organizations who find themselves using it and proving its utility immediately before and during the most extreme of all possible circumstances. And it is being used by mental health practitioners after a stressful circumstance to teach survivors to master their physiological response and thereby prevent PTSD.

In the aftermath of the March 1998 Jonesboro school shootings, I taught the technique to the mental health professionals and clergy who had gathered that first night. The plan was for me to conduct the initial briefing, establishing the cognitive foundations for what would follow, including training and rehearsing the breathing techniques. The survivors would be broken into small groups and work their way through their experiences, one by one. During the debriefing everything but anxiety is permitted. Laughter and tears came out, but as soon as individuals began to show anxiety, usually manifesting itself in hyperventilation, then they were made to stop and breathe. Thus the survivors of this terrible, tragic event were able to confront the memories and emotions, while working from the very beginning to “de-link” them from any kind of physiological response.

The next day the mental health professionals, clergy, and teachers conducted debriefings with the children, using the same techniques and the same rules. The results were very good. You cannot truly measure success in such circumstances, but there were immediate, positive responses from counselors and subjects, and a host of anecdotal support for the technique and its application in this circumstance. In one case, a mother complained to a counselor that she was so anxious that she had not been able to sleep for two nights. The counselor reports that he had her do one cycle of autogenic breathing–three deep breaths–and her next response, to her amazement, was simply to yawn. Also, there have been no suicides associated with the Jonesboro shootings, although there have been many resulting from the Littleton, Colorado, school shootings and the Oklahoma City bombing.

You Are Only as Sick as Your Secrets

If we understand that the “universal human phobia” is close-range, interpersonal aggression, and that we are systematically enabling our combatants to kill in combat, then we can also begin to understand that aggression from a human enemy will result in a magnitude of trauma that is generally unlike anything else that a human being can encounter. If you have never experienced such a trauma, you are apt to try to place it in terms of your own experiences and traumas, but the reality is that this will be a fundamentally flawed exercise.

Perhaps one of our greatest handicaps in attempting to identify with the victim of human aggression is the fact that we cannot help but be influenced by Hollywood. I like to ask my audiences or psychology classes, “All’s fair in…what?” And they always answer, “Love and war.” “That’s right,” I respond. “You see there are two things that men will often lie about. They will lie about what happened on that date last night, and they will lie about what happened to them in combat. And therefore that means that what we think is happening in combat is actually based on 5,000 years of what?” And the answer is always, “Lies.”

Truly, Hollywood lies to us, and we cannot help but be influenced by these lies. There are a wide variety of profoundly distressing physiological and psychological responses to close-range interpersonal aggression. These include loss of bowel control, sensory gating, loss of fine and complex motor control, and memory loss. For example, in one major survey conducted during World War II, a quarter of all combat veterans admitted that they urinated and defecated in their pants in combat. (Those are the ones who would admit it. The actual number may be quite a bit higher.) Among those wounded, defecation and urination are almost universal. But you never read about that in the books or see it in the movies, do you? Yet this is just the tip of the iceberg of deception and lies that we must confront when we begin to examine the impact of close-range interpersonal aggression.

To fully comprehend what happens to an individual in such a circumstance we have to realize that sympathetic nervous system (SNS) activation has become completely ascendant, shutting down all parasympathetic processes such as digestion. Furthermore, and most importantly, a frightened or angry individual has a shutdown of the forebrain, resulting in a powerful midbrain, or mammalian brain ascendancy, which is purely and absolutely focused on one thing: survival. One result of this is that the midbrain (which is a relatively simple mechanism, incapable of denial or transference) says “Hey! Something very bad just happened, figure out what it is and don’t ever let it happen again!” Of course the midbrain does not speak to us in words, but rather in bursts of emotion, and those emotions are translated, all too often, into a sense that, “It is all my fault.” During the critical incident debriefings after the Jonesboro shootings, many of the survivors (including 11, 12, and 13-year-old children) said, at some point, “It was my fault.” And the ones who were best able to convince them that it was not their fault were the individuals who shared the experience with them.

Perhaps the most distressing response of all is the common, immediate, “survival instinct” reaction of intense relief after witnessing violent death, even the death of a loved one, which is often articulated as, “That could have been me!” or, “Thank God it wasn’t me.” The midbrain can be mercilessly logical, and it is intent on survival. In order to be able to help someone else survive you must, generally, first survive yourself. It is like the passengers on an airplane, who, “In case of loss of cabin pressure,” must “…put your own oxygen mask on first and then assist any small children traveling with you.” In a mercilessly logical system you must acknowledge that in order to help your children survive you must, with few exceptions, first survive yourself. Of course, afterward, this initial, self-centered impulse can result in powerful guilt feelings if not addressed.

During the initial inbriefing for the teachers who survived the shootings in Jonesboro, I outlined to them: what would be happening, the moral obligation to participate, the need to “de-link” the memory of the event from anxiety, the breathing exercise that would help in this “de-linking,” and some miscellaneous things that they needed to know up front. One of the things I addressed was the loss of bowel and bladder control, the memory loss, sensory gating, and visual narrowing (tunnel vision) that was very common and perfectly natural. Then I outlined the irrational acceptance of responsibility and the common human reaction of “Thank God it wasn’t me,” after witnessing violent death. After I told them this last item, this “Thank God it wasn’t me response,” and told them that it was a perfectly natural and common response, several of these teachers laid their heads in their arms and began to sob uncontrollably. They had experienced the intense relief of having their deepest, darkest secret laid out on the table, only to find out that everyone else had the same secret in common, and it was OK. They were perfectly normal. There was nothing wrong with them if they felt this way.

Perhaps half of the essence of counseling is that you are only as sick as your secrets, and until we begin to address some of these secrets we will never truly be able to assist fully in the healing process. The other half of the essence of counseling may be that pain shared is pain divided. And the means by which this “sharing” can occur is in a group critical incident debriefing, shortly after the trauma, in which each individual works completely through what occurred and receives the acceptance, forgiveness, and support of their fellow victims.

Conclusion: An Application to PTSD Resulting from Killing

Thus we have seen that there is a powerful resistance to killing in most healthy human beings. We have also seen that military and law enforcement organizations around the world have initiated a powerful conditioning process, through military combat training, that has enabled combatants to bypass this resistance. An extraordinarily high firing rate resulted from this process among US troops in Vietnam, British troops in the Falklands, and among modern US law enforcement officers.

But conditioning which overrides such a powerful, innate resistance has enormous potential for psychological backlash. It has been noted that every warrior society has a “purification ritual” to help the returning warrior deal with his “blood guilt” and to reassure him that what he did in combat was “good”. In primitive tribes this generally involves ritual bathing, ritual separation (which serves as a cooling-off and “group therapy” session), and a ceremony embracing the veteran back into the tribe. Modern Western rituals traditionally involve long separation while marching or sailing home, parades, monuments, and the unconditional acceptance of society and family. As was noted previously, after Vietnam this purification ritual was turned on its head, and America paid a tragic price, with anywhere from 0.5 to 1.5 million cases of PTSD occurring as a result of our conduct of that war.

One vital, age old aspect of this “purification ritual”, can and has been, reintroduced since Vietnam and that is the “debriefing,” conducted every night around the campfire. The introduction of 24-hour combat for months on end in World War I created an environment in which it became impossible for the soldier to perpetuate this ancient, nightly ritual. Throughout the 20th century the opportunity to conduct a daily processing of combat experiences disappeared from the battlefield. The group critical incident debriefing is not a new occurrence on the battlefield. The absence of this daily debriefing is what is new, and now we are reintroducing this ancient process, with a degree of systematic, scientific expertise that has never occurred before.

Today, there is a moral, medical, and legal obligation to conduct these group debriefings. These debriefings must include all of the individuals who were involved in the critical incident, or, if that is not possible, individuals who were involved in similar incidents. Any organization that sends individuals in harms way, and especially any organization that calls upon humans to participate in the psychologically toxic realm of interpersonal aggression (which is, perhaps, the “universal human phobia”), and does not subsequently conduct a critical incident debriefing is morally, medically, and legally negligent.

Furthermore, there must be an environment wherein there are no “secrets” to be kept, since the perpetrators may well be “only as sick as their secrets.” That means, to the utmost of our ability, we create an environment of transparency and accountability in which no atrocities or criminal acts can occur, since these are the ultimate “secrets” which often cannot be confessed and must be kept at all costs. Col. Greg Belenke, a psychiatrist and head of one of the combat stress teams in the Gulf War, has definitively stated that atrocities and criminal acts are one of the surest paths to PTSD. PTSD can be thought of as “the gift that keeps on giving,” since it impacts not just the perpetrators, but also their spouses and their children in the decades to come (Belenke, 1996).

Rachel MacNair, in her research, has found that: “The item, ‘There were certain things I did in the military I can’t tell anybody,’ was a strong indicator of the perpetration groups in just about every way I looked at it. When I compared those who were directly involved in the killing of civilians or prisoners with those who witnessed that but were not directly involved, yet did kill in other contexts (presumably more in line with traditional combat), the two items that differentiated were that one and nightmares” (R.M. MacNair, personal communication, June 15, 2000).

This means that atrocities, the intentional killing of civilians and prisoners, must be systematically rooted out from our way of war, for the price of these acts is far, far too high to let them be tolerated even to the slightest, smallest degree. This means that we enter into an era of transparency and accountability in all aspects of our law enforcement, peacekeeping, and combat operations. This also says something about that those who are called upon by their society to “go in harm’s way,” to use deadly force, and to contend with interpersonal human aggression. These individuals require psychological support just as surely as they require logistical, communications, and medical support. Thus, as our society enters into the Post-Cold War era, the fields of psychiatry and psychology have much to contribute to the continuing evolution of combat, and to the evolution of our civilization. 

Excerpt from Lt. Col. Dave Grossman

 

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