I think if I were you, in case my mind were not exactly right, I would avoid being idle.
—ABRAHAM LINCOLN, letter to friend Joshua Speed, February 13, 1842
Movement is a medicine for creating change in a person’s physical, emotional, and mental states.
—CAROL WELCH
Firefighters, police, and the military—those whose daily work involves the highest incidence of stress and trauma—know that exercise and keeping fit are necessary to counteract the persistent strain and upset of their work. (And I appreciate being reminded of this often when I go for walks at the Santa Monica beach, where the local fire department sends their crew to jog—they are inspiring as well as lovely to watch.) These experts have a lot to teach us about managing the effects of traumatic stress. Their experience could be useful to you as well: Carefully chosen physical activity will make a meaningful contribution to your recovery from trauma.
There is a medical term for the trend in Western civilization toward less and less physical activity: sedentary lifestyle. It has become a general problem, at the root of increasing rates of obesity, heart disease, and other (often) preventable conditions. The benefits of exercise for physical health have been studied widely. Its application to reducing depression has a significant body of research. Less explored, but no less important is the potential for activity and exercise to relieve the symptoms associated with trauma and PTSD. Just about everyone I have worked with has benefited. However, most have also begun reluctantly.
Jack comes to mind first. He was not long out of college when I first saw him. He was thin and frail, and still suffering greatly from his childhood. The worst of his traumas included his mother’s regular bouts of physical abuse and bullying by several schoolmates. In his early 20s, day-to-day life was difficult for him. He was lucky to find work that demanded little of him while providing a nominal income and a daily structure. He sought me out with great hopes that I might instantly cure his ills and set him on his life path.
The major thing that struck me about Jack was his obvious physical weakness. He was pale, slouched, and had very little muscle tone anywhere on his body; his clothes hung off bones. I could not imagine how he would withstand the rigors of his life, let alone the demands of trauma therapy. Simultaneous to addressing emotional issues, I strongly recommended he begin an exercise regime. Specifically, I counseled that increasing his muscle strength through weight training might help him feel stronger in mind as well as body. His youth was a great advantage and lent him a level of enthusiasm that was an ally to his recovery. After a short period of skepticism, he took to physical exercise like a fish to water, such a natural at it that I wondered why he or someone else had not thought of it before. He loved lifting weights and marveled at the evidence of success he could see in the mirror from week to week as his physique developed. Alongside his bigger muscles, his psychological state began to stabilize and his courage to increase. One day he astonished me with the announcement that since he had so much more energy, he had taken a more challenging job at a higher wage. He proudly insisted that we increase his nominal fee.
This may all sound like a miracle, but it was also a lot of hard work on Jack’s part. He had to structure his life differently to fit in the exercise program he designed for himself. That included devoting less time to television at night so he could get to bed early and get up early. The trainer at his gym coached him in nutrition. Jack took on his physical improvement as the primary project in his life.
Of course his improved condition did not solve his childhood problems. But it did change his relationship to them as his current life improved. What was going on now became his priority; feelings about then became less acute. After about a year and a half, he decided he did want to talk about what had happened to him as a child. By then his stability was so improved physically and emotionally (see Phase I in Key 3) that I was very willing to accompany him down that road (Phase II).
Most of you reading this book will not need or achieve the level of bodybuilding that Jack did. However, each of you will likely gain something useful if you get moving. Just make sure to plan your program with an eye to appropriate exercise and activity tailored to your own body’s capabilities and limitations and your emotional needs.
The Issue
Moving—exercise and fitness—as it applies to safe recovery from trauma has at least three potential benefits:
As An Antidote to a Persistent Freeze Response
People often bog down in the aftermath of trauma. As discussed previously, they often get stuck in the past. In addition, they can become fixated on their bodies. Symptoms of posttraumatic stress tend to be very unpleasant, even paralyzing. In the aftermath of trauma it is tempting to pull in, to reduce the amount and scope of activity. Trauma can make it difficult to go to work or even get out of bed. Of course, when physical injury is involved, that must be addressed first. But when the lasting impairment is primarily psychological, as is the norm with PTSD, physical symptoms may still be plentiful. To get moving reinforces the epilogue (see Key 2) by sending an active, nonverbal message to the body and the mind that there is no longer a need to freeze, or that the freeze response has ceased, because the trauma is over.
When Kate’s house was burglarized in the middle of the night, her husband quietly called the police and then snuck downstairs with a baseball bat to confront the robbers. Kate knew what was happening, but was frozen with fear, unable to move from her bed throughout the entire incident. She wanted to hold her husband back from confronting them but was unable to move or utter a sound. Luckily the police arrived quickly and no one got hurt. The burglars were apprehended. However, 2 years later, Kate remained housebound, afraid to go out. The only excursions she could tolerate were quick grocery trips and other short errands. Her body had become stiff with chronic remnants of the paralysis she experienced the night of the attempted robbery. And her husband was worried about (and frustrated with) her.
Kate was not willing to come to my office, so at first I made home visits. We worked with various strategies, most contributing to improvement. However, it turned out to be simple physical exercise that helped her make the biggest strides. Of course she would not go to a local gym. But she was willing to increase her activity at home. They bought a treadmill and Kate began to walk daily, building up to several miles over a few months. Gradually she added other physical activities, including stretching and push-ups.
The exercise helped her to feel more in control again and she became interested in fixing up the garden. That actually gave her a huge boost as she spent several hours most days with soil and plants. She reminded me what good therapy gardening can be for many people. One night as she had a repeating nightmare about the burglary, something in it changed. Instead of the usual dream of being frozen in her bed, she found herself on the stairs with a shovel in her hands. When one of the robbers came near, she whacked him with it. For the first time in 2 years she woke with a smile on her face.
Kate still had some distance to go in resolving the burglary trauma and getting her life back on track, but she had made great strides. Physically intervening in chronic freeze had shifted something deep inside her. Both the exercise and the gardening were important. A few months later she decided to take a self-defense class to increase her confidence and sense of security. Though she hoped her home would never be burglarized again, if there was a next time she wanted to be able to really smash the offender with a shovel.
To Increase Containment and Self-control via Increased Muscle Tone
Muscle tension is an underrated ally. While relaxation can be valuable at times, without muscle tension you would be unable to stand, walk, sit, or hold this book in your hands. Tension helps us complete the tasks of daily life; without it we would be immobile. Of course there are degrees of tension that can be unpleasant and even cause difficulty—like almost anything else, the extremes of tension, particularly chronic tension, are not particularly helpful. Though most people would assume relaxation is the state that helps trauma recovery most, a good portion of traumatized individuals do not do well with relaxation. In a relaxed state, they may actually become more anxious or even panicked.
Jack and Kate, above, are good examples of this exact problem. When I first met them, they both were out of control of their anxiety. Jack had tried listening to relaxation CDs and Kate was attempting progressive relaxation. However, neither of them was helped by loosening up. In fact, Kate’s symptoms actually worsened when she was practicing the relaxation method. The strategy that turned the tide for each of them was increasing the tone of their muscles. When they were physically stronger, they became emotionally stronger as well.
To Dissipate Buildup of Stress Hormones and Help Regulate Ongoing Stress Levels
Sports and aerobic exercise help us blow off steam. And with that steam dissipates a portion of stress hormones. This is a main reason that those with highly stressful work, as mentioned above, will run, play football, or work out vigorously and so on. A growing body of research continues to underscore the value of exercise in reducing the effects of stress. It does this through several actions. One of the results is an increase in endorphins, those brain chemicals that make us feel good. Another is a reduction in chronic adrenaline levels as the exertion uses it up.
There is a caution here, however: Not all trauma survivors are able to make use of strenuous exercise. Some may need to engage at a lower level of activity, at least at first. The traumatic stress reaction increases heart rate and breathing, so activities that do likewise can trigger flashbacks in some traumatized individuals. That is not helpful. For them, beginning with exercise that does not increase pulse and respiration is the better tactic. Slow, purposeful weight training, beginning with light weights (including milk cartons and the like), can be a good starting point. See my own story, below, for more on this principle.
The most important thing is for you to find the type of exercise that improves your situation. Using your mindful gauge as well as common sense will help you to identify what is best for your body, your mind, and your circumstances.
The Case
My own PTSD had roots in a couple of childhood incidents. For the most part, through my teens and college years, I was unaware of the impact those incidents had and would have on me. There were minor bouts with stress or anxiety, including some insomnia in high school. But for the most part, my life moved forward fairly normally. However, in my early 30s, I began to have increasing trouble, including the development of panic attacks. This peaked at the beginning of the 1980s when PTSD was a new and rare diagnosis. The therapists I sought help from at that time had never heard of it and neither had I. No one understood why I was having so much trouble dealing with my feelings and everyday life. As my difficulties increased with regular bouts of anxiety and panic, my life became more and more restricted. Soon I had added agoraphobia to the mix of my difficulties. I was not quite housebound, but increasingly limited in what I dared to do. Even trips to the grocery store became a major emotional challenge. Typical of PTSD, I felt out of control of my mind, my body, and my life. Many factors were involved in the breakdown of my emotional and mental systems. It took several years and a variety of strategies to get me fully back to myself. Perhaps I will write about my whole experience in a memoir someday. But in this chapter, I want to focus on the central role that getting myself moving played in beginning and sustaining my own recovery from trauma.
Apply a Little Theory
When you get moving, you will be accomplishing at least two important goals for trauma recovery: Counteracting any lingering freeze response in your system and increasing the capacity of your body to contain the arousal of the traumatic stress response. In this section, we will look at the theory that underlies these important interventions.
Counteracting Freeze
While often a lifesaver (as discussed in Key 5A, “Forgive Your Limitations”), freezing in response to trauma has consequences. In fact, it is believed that dissociative reactions, including freezing, during a traumatic incident predict PTSD. That is to say, those who freeze rather than fight or flee have the greatest possibility for developing long-term problems. So if you have PTSD, it is likely you froze during one or more traumas.
The freezing reaction can continue to be triggered after a trauma is over via flashbacks. Something in the internal or external environment serves to remind your amygdala (see Key 1) of the trauma and the reaction is set in motion. One strategy for countering habitual paralysis is to train yourself to move—even if only a little—whenever you freeze. A movement as simple as standing up, walking a few steps, or even just lifting your finger or arm a few inches can break the freezing “spell.” When I am working with people who are or become frozen, I will ask them to wiggle their fingers or even to look at the clock, just to get them moving. Such a minor intervention sends a powerful message to the amygdala that the trauma is actually over because now you can move.
The Body’s Container
Muscular relaxation (e.g., via massage, yoga, stretching, soft furniture) is a frequent goal of stressed-out people. Of course that can be ideal for many. But for a good portion of those suffering traumatic stress, the value of relaxation is highly overrated, even misleading. A number of you reading this now may already have noticed that the more relaxed you get, the more nervous you become. It is possible you have not told anyone because you thought something was wrong with you. I hope it will be a relief for you to know this is a common reaction in those with PTSD and also persons with anxiety and panic problems. A full 4% of the general population is believed to get more anxious from attempts at relaxation, though it is not possible to translate that into the exact numbers of those with PTSD.
This unexpected phenomenon can be particularly (and frustratingly) demonstrated at bedtime. A common scenario finds the exhausted trauma survivor lying in bed dazed by the amount of anxious energy coursing through her body. What happened? She was ready to sleep, but as soon as she relaxed and started to drift off, her body became highly agitated and uncomfortable. All of a sudden she was completely awake with no hope of sleep—another cycle of insomnia had begun. For some of these traumatized insomniacs, attempting a gentle muscle tensing before sleep will help to contain the stress arousal just enough to allow sleep.
No one is really sure why increasing muscle tone helps people with PTSD; however, we can speculate. In part, any benefit will depend on where in your body you increase tone. For example, increasing tension in the legs, feet, and back may improve your balance and ability to hold yourself up. More tone across your chest or back can help you to feel more protection—armor—between yourself and others.
A particularly emotionally fragile Danish client, Tina, had difficulty at large family gatherings where a buffet lunch was the traditional norm. Every time she went to the food table, with her back to the room and the other people, she would become so nervous she could not fill her plate. She rarely ate much at those gatherings. Even more problematic was her increasing emotional discomfort. She considered giving up going to gatherings altogether.
In reviewing the scenario with her mindful gauge, Tina was able to identify that it was an extreme feeling of vulnerability that made her so uncomfortable turning her back to her family. Neither of us had ever encountered such a problem before, so we agreed to just experiment and see what, if anything, might help her. Through trial and error we discovered that having Tina tense the area between her shoulder blades, by pulling them toward each other, significantly reduced the vulnerable feeling. However, by pulling her shoulders back, she felt too exposed in her chest. More experimentation led to a rather awkward pose involving pulling together her shoulder blades while simultaneously tipping the upper edges of her shoulders forward and down. Admittedly, it was a bit weird. But it worked. In that position Tina felt like she had on a suit of armor, that she was protected. If she could maintain the necessary posture, she believed she would be able to get something to eat. I suggested that the more she practiced, the easier and more subtle the necessary tensions would become. And over a few weeks’ time it did become more automatic for her. At the next family reunion, she was able to get a plate of food without emotional difficulty, even if she did still feel a bit stiff in her movements. The experiment was successful.
A plastic bottle of soda helps to illustrate my hypothesis for why muscle tensing helps emotional containment. I figure that the soda is under pressure inside its flexible container, which is somewhat akin to the kind of pressure that is inside the body and musculature of a person with PTSD. If the bottle is too soft, the pressurized pop contents will not be well contained. They could leak all over the place. I see a parallel to trauma-pressurized people; their container also needs to be firm like the plastic soda bottle, to keep the pressure of their traumatic stress in check and manageable. Muscle tone increases the firmness.
Discovering My Key
Because I felt so vulnerable, I knew that any exercise would have to be graduated, starting simple, easy, and slow to avoid aerobic stimulation. If I could just build up without increasing my heart rate, that would be ideal. Further, I would have to do it at home, as going to a gym would be an over-the-top challenge. For me to be able to succeed at this, I would have to make it safe for my then-fragile psyche.
I made two investments: a pad of graph paper and a very cheap set of free weights. I used the graph paper to plot a program. Down the left side I listed my starting exercises: bicep curls, side leg lifts, back leg lifts, wall push-ups, and barbell lifts. Across the top I used one tiny square for each day I would “work out,” putting the dates along the top. I started with three days per week. I wrote work out in quotes above because I could not really call it that. The first day I only did about three repetitions of each activity: three curls, three lifts with each leg, three wall push-ups, and so on. I did not dare to do more for fear of raising my pulse. However, I did each one and recorded the number of repetitions on the graph paper. It was a relief just to do something proactive. Two days later I did four repetitions of each exercise. Every subsequent exercise day I would increase the number of repetitions by one. It seemed pitifully little to do and slow to build. But the fact remained that I was doing something. And I was moving my body without triggering panic. On the contrary, fairly quickly I discovered that my stress level was less and my breathing was easier immediately following the exercises. Gradually I began to see slight improvements in my stability when I was at home and when I went out. Do not misunderstand me—this was not a quick miracle cure. I do not remember exactly, but it probably took a year before I was back to mostly normal activities. But fairly early on I could see that using and building up my muscles was having a positive, if very slow, effect.
Since that time, exercise remains a loyal friend. In fact, I am sure it is one of the ways I continue to manage the stress of my life and the growth of my career. During my years living and working in Denmark, walking was my major means of transportation. I also began regular swimming while living there. Today, back home in Los Angeles, I exercise regularly, including swimming and walking. Over the years I have become convinced that my mental health and physical health are intertwined, so I do what I can to support both.
Applications for You
What helped me back then was the combination of structured activity (recorded on my graph paper) and a gradual buildup of muscle tone. Those may help you, or it may be something quite different. How you get moving must be tailored to your needs, body, mind, and situation. Perhaps walking or taking a Pilates class will be best for you; maybe weights or jogging. Do not be limited by my examples or exercises—please think outside the book. What is good for your friend may not be good for you and vice versa. Though I could not manage aerobic exercise when I had PTSD, you might do well with it. Use your mindful gauge to imagine different ways you might get moving and choose experiments based on the responses of your gauge. Then try a little of whatever seems most likely and evaluate again before settling on your plan.
It will be important to work your personal program into some kind of a routine or schedule. Regular activity at a level you can manage well will quickly become self-rewarding. There is a common wisdom about exercise: Once you get into the habit of it, the longer you keep at it, the easier it becomes to keep up. The rewards build and will help you to stay active once you have gotten over the first few humps.
Before You Begin
There are criteria to consider before committing to an exercise program, including the following:
Exercise 1: Find Your Activity
Imagine different types of exercise: walking, jogging, types of weight lifting, sit-ups, push-ups, Pilates, yoga, step class, bicycling, treadmill, and anything else you can think of. You might start by imagining one or two, or go through a whole list at one time. Make sure you only attempt a portion you can manage. Then use your mindful gauge to identify which—if any—you would actually like to experiment with. Then arrange to try them one at a time. When sampling, make sure to apply your mindful gauge as well as common sense to each to find which is best for you at this time. Remember to include options such as team sports, gardening, and so on, anything that involves physical exertion or increasing strength. It could be a bonus if you find something to do with others, giving you contact at the same time you build your physical and emotional stability.
Exercise 2: Set Up Record Keeping
Would a log help you to maintain a regular schedule of activity? If so, what would work for you? For me it was a graph, but for you it may be something different. Would you like to buy small stars or other types of stickers to record your progress? Or maybe you will put an amount of money in a can each time you exercise, then use the collection for a big treat. Anything that would supportively encourage you to keep at it is fair to try.
Exercise 3: Find an Exercise Buddy
Remember that contact and support are also important factors for your recovery. Exercise and sports can be a source of companionship. For many, exercising and sticking with an activity program is easier and more fun when done together with a friend or acquaintance. Consider who you know who either is already exercising or could use help getting up and out. If you are not ready to exercise together with another, you could still have support through regular phone or e-mail contact reporting on or discussing your get moving program. In that way you might also support someone else who needs to get moving (see Key 8, “Make Lemonade”).
Evaluate This Key
This might be one of the easier keys for you to evaluate as many of your reactions, positive and negative, will be highly physical and relatively immediate. Have you found the right activity? Is the effect purely physical, or can you also see an impact in other areas: emotions, outlook, and such?
Plan How to (or Not to) Use This Key
If you find you are not doing your set exercise program, refer back to the chapter on smaller steps (Key 6). It is likely you have tried too much or begun too soon. Reduce the amount or renegotiate your timing. Keep adjusting until you find something you can and will do and stick with. Remember, I had to start with just three repetitions of a mere handful of exercises. Even if it is only one, that could be the right place for you to start.