Book Excerpt: Mindsight by Daniel Siegel, MD

You’ve likely encountered Dr. Daniel Siegel at some point in your psych reading.  If not, now’s the time.  Dr. Siegel is a pioneer in interpersonal biology, examining the way our brains are wired, how experience alters that wiring, and how new experience–particularly therapy and mindfulness practice–can help us restore our brains and sense of well-being.

Dr. Siegel is author of an impossible-seeming number of books,  including Parenting from the Inside Out, The Mindful Brain, and, coming later this year, The Mindful Therapist. His most recent release is Mindsight: The New Science of Personal Transformation, which explores the interplay of brain science, psychology, and mindfulness. Take a look:  here, reprinted with permission, is an generous excerpt:  Chapter 7, “Cut Off from the Neck Down.” Enjoy.

Mindsight: The New Science of Personal Transformation

Chapter 7

Cut Off from the Neck Down – Reconnecting the Mind and the Body

Anne’s first visit was on a rare rainy day in Los Angeles. She must not have brought an umbrella, because her long black hair was soaked. It was bundled into a loose knot at the side of her head, and a stream of moisture was quickly darkening the shoulder and neckline of her jacket. I couldn’t help watching the dark spot spread, but Anne didn’t seem to be bothered. I’d soon learn that this lack of interest in her body was more than just a passing state of being caught off guard in the rain.

Anne looked around the room, slouched back into the couch, and said, “Well, here I am, but I’m not sure why.” Anne was a forty-seven- year- old physician and the mother of eleven- year- old twin girls. She told me that she had been putting off going to her internist for a follow- up exam for more than a year. Her slightly raised blood pressure and some findings during a routine heart exam had concerned him, and he’d asked her to return a few weeks later, but she just hadn’t gotten around to it. Yes, Anne told me, she knew that doctors made the worst patients. But she felt that there was nothing wrong with her heart and she didn’t need to waste her time. Her blood pressure was fine now; she just had a few palpitations that she was pretty much able to ignore.

So, I asked myself, if her heart was really of no concern, why was she talking about it? “I don’t have time to see any doctors,” Anne continued, the words tumbling out. Her life was stuffed to the brim with work, she said, her long days spilling over into weekends spent at the office where she was in charge of a group of radiologists. I wondered, too, how she had made time to see me– and why she’d really come. Anne looked lost, and behind her eyes seemed to be a distant sadness, a kind of longing for something she couldn’t find. My own right mode was filled with a vague sense of pain, but at this point I couldn’t place it, couldn’t name it, so I just noted these internal sensations and filed them away in my mind.

Anne then told me that even with her professional success, she didn’t feel very accomplished, and that her life was empty. There wasn’t much else besides work. She had divorced her husband six years ago because “they just didn’t have much in common.” She hadn’t been interested in dating when the twins were younger (besides, she was too busy), and she wasn’t in a current relationship. Her daughters divided their time between her house and her exhusband’s in a nearby neighborhood. When I asked her about her relationship with the girls, she told me that they were “miniteens” who ” didn’t really want to bother with their parents.” They were “very independent,” she added proudly. Anne paused for nearly a minute, and I waited to see what else she would say. Then she looked at me with a puzzled expression and said, “Well, I’m here anyway . . . and I guess there has to be something more to life than just this.” I took that to be a request for therapy.

When I asked Anne to tell me something about her upbringing, this is the story she told me:

When she was three years old, Anne’s mother died of lung cancer and her father became very depressed. She was sent to live with her mother’s parents in a nearby town, and she didn’t see her father again for almost a year. During that time her father had been hospitalized, and when he was released he returned to live with Anne and her grandparents. When I asked Anne about that year, she said, “They were caring people, warm and loving,” and then she paused for a few moments. “But it didn’t last long,” she added. “I was young, and my father came back, and, well, it all changed after that.”

Anne’s father remarried when she was five years old, and the new family moved across the country to settle in the Pacific Northwest, near Seattle. She didn’t see her grandparents again until she was in college. Anne’s father and stepmother had two more children, active boys born a year and a half apart, whom they doted on. Anne said she loved her brothers but felt ignored by her father. As for her stepmother, Louisa, she was “a robot of a woman” and a harsh disciplinarian who criticized Anne relentlessly. Anne’s father never intervened.

One day when she was eleven years old, Anne had a particularly painful dressing- down from Louisa. Later, as she told me, she went for a long walk in the apple orchard in back of their house. She remembered making a decision: She promised herself that she would “never feel anything again.” As she told me this, her face grew even more vacant, and she drew her index finger straight across the front of her throat. It was the gesture most people would recognize as “it’s over” or “off with his head.” But I wasn’t at all sure Anne even knew she had made it.

“It worked. They could never touch me again. I mean, they didn’t hurt me physically or sexually abuse me, but I never let them make me feel bad, no matter what they came up with. He and my step-mom just became nonpeople in my life. I ignored them from then on. I worked like crazy in school. My teachers loved me, and that was that. After college and medical school, I knew I would be okay. I think in many ways it all helped me become the successful physician I am today. I suppose I should thank them…all of them… but I don’t speak with them anymore. They wouldn’t know what to do even if I did, I mean, to say I’m sorry, if they could. That’s it. That’s my story.”

The session was over. Anne agreed to return, and then she went out into the rain.

KEEPING THE BODY OUT OF MIND

Halfway through Anne’s second visit, a quotation from James Joyce that I’d heard somewhere popped into my head: Mr. Duffy “lived at a little distance from his body.” It was in the way she moved, the stiffness of her gait, the way she held her hands motionless in her lap. (Her throat- cutting gesture stood out even more in retrospect.) It was also emerging from her account of a limited, rigid inner life lived only above the shoulders.

Anne told me she’d been quite artistic as a child– she’d excelled at drawing and loved to paint– although she’d had “no time for such things” in years. Unlike my patient Stuart, she did not seem to have a deficit in right- mode development; this was suggested by her artistic abilities and the fact that during her recounting of her personal history it was clear that she was aware of and able to articulate autobiographical memories in great detail, a specialty of the right brain. Moreover, sitting with me in the office, she expressed herself well nonverbally, making good eye contact and varying her facial expressions and tone of voice as different issues came up, which are other signs of right- mode development. Her left mode had also shown early strength; she’d been at ease with science and loved to solve math problems when she was in school. Her success as a radiologist supported my impression of at least some degree of horizontal integration; her profession required combining the spatial pattern recognition of the right mode with the analytic clinical mode of the left.

In our initial interview, Anne had spoken only briefly about her reaction to her mother’s death: “She died, I was young, and I don’t know what I would do without her.” This confusion of past–“I was”–and present tense–“I don’t”–is a window into possible issues of unresolved grief. I thought about how her mother’s illness must have affected their relationship even before she died– how confused and frightened a toddler would be by her mother’s inability to care for her. She had also experienced the sudden loss of her father, who disappeared and later returned, only to remain distant; and then she was taken away from the grandparents who’d cared for her lovingly for two years.

Next there was Anne’s “decision” as an eleven- year- old “never to feel anything again.” Anne spoke of this as a turning point in her young life. As I asked questions about her current experiences, the cutoff from her body became clearer. Anne “ate to live” and took little pleasure from food. She said matter-of- factly that she’d “never been a particularly sexual person.” She’d never been involved in sports, and she had no physical fitness program.

The disconnect from her body wasn’t complete, however. There was the matter of her palpitations. I asked Anne about their quality, frequency, and intensity, and she was able to tell me that they happened a couple of times a week, were “only mild” but– in contrast– “unnerving” enough to make her stop whatever she was doing. She couldn’t pinpoint anything that caused them. When I asked if she could sense her heart when it was beating normally, she said that she could not. But these sudden onsets of rapid, sometimes pounding, and irregular heartbeats “bothered” her. I urged her to go back to her internist to be sure there was nothing to be concerned about. She said that she’d “think about it.” Anne was an expert observer of interior anatomy in all its subtleties, but she refused to pay attention to her own body.

ESCAPE FROM PAIN

Anne had adapted to a painful situation by shutting off awareness of her feelings. What’s wrong with that, you might ask? If our adaptations allow us to survive, why challenge them? Here’s the basic problem: The conditions Anne experienced as a child– the painful loss of her mother and grandparents, her new family’s neglect and harshness– no longer existed. She had adapted as best she could, but she’d had no support to help her resolve her losses– then or now. So her adaptation, which initially gave her strength and enabled her to move forward in her life, actually had come to imprison her. It kept her from being able to thrive.

Anne’s decision to “never feel anything again” had effectively shut off the body proper from the neck down. It was as if she were trying to take refuge in her cortex, to cut herself off from the ongoing pain of criticism and isolation and unfairness. This adaptation may also have helped her leave behind– out of her awareness– her unresolved grief over her first great loss, her mother’s death, which preceded all the others. Like all emotions, such overwhelming feelings are created throughout the extended nervous system, in the body, brainstem, and limbic areas; they directly involve our cortical regions as well. But if we can find a way to block subcortical input, if we can keep it from traveling upward into our consciousness-creating cortex, voilà!–we’ve “eliminated” our feelings.

No one knows exactly how our mind uses the brain to defend us from pain, but two things we do know from repeated clinical experience. One is that people do this quite often. As you’ll see throughout this book, these adaptations can take many forms, from avoiding our feelings momentarily when we are overwhelmed, to long- term shutoffs, or to shutdowns like Anne’s. The second thing we know is that somehow we– that is, our minds– can modify neural firing patterns to create what we need. For example, when we need to place something in the front of our mind, to focus our attention, we activate aspects of the prefrontal cortex on either side of the brain. So we can propose that one possible way the mind uses the brain to block something from awareness is by literally dampening the neural passage of energy and information from the subcortical regions upward to the cortex, especially to the parts of the prefrontal region that mediate awareness.

Here’s another thing we know for sure: When we block our awareness of feelings, they continue to affect us anyway. Research has shown repeatedly that even without conscious awareness, neural input from the internal world of body and emotion influences our reasoning and our decision making. Even facial expressions we’re not aware of, even changes in heart rhythm we may not notice, directly affect how we feel and so how we perceive the world. In other words, you can run but you cannot hide.

Colleagues of mine at UCLA have recently demonstrated that the pain of social rejection is mediated in an area of the middle pre-frontal cortex that also registers physical pain from a bodily injury. This area is called the anterior cingulate cortex (ACC) and it straddles the boundary between our thinking cortex and our feeling limbic regions. In addition to registering physical sensations from the body and feelings from our social interactions, it regulates the focus of our attention. Because it links body, emotion, attention, and social awareness, the ACC plays a key role in the resonance circuitry that lets us feel connected to others and to ourselves. (In fact, the more we can sense our own internal world, utilizing the ACC and related areas such as the insula discussed in the Minding the Brain section “Riding the Resonance Circuits,” the more we can feel the internal world of someone else.)

These research findings give us a new way to think about Anne: Her young mind would have been as driven to obliterate the chronic pain of loss and rejection as she would have been to escape physical pain. If she could shut down the activation of her ACC, perhaps she could “eliminate” the awareness of her pain. Standing in the apple orchard, Anne had found a way to exclude that pain from her conscious experience. The problem is, you can’t eliminate bad feelings and keep the good. If you block lower input from reaching the ACC and the insula, you’ve blocked the source of emotion from reaching awareness. The result was a deadened emotional life and a cutoff from the wisdom of the body. The insula and ACC also appear to work together to create an overall self- awareness–something that seemed to be impaired in Anne as well.

BRAINSTEM SIGNALS: PAY ATTENTION! FIGHT, FLEE, OR FREEZE?

We gain access to the body’s wisdom through interoception, which literally means “perceiving within.” Try pausing for a moment right now and just become aware of the beating of your heart and the in-and- out of your breath. These basic physiological processes are regulated by the brainstem; the brainstem also helps regulate our cortex by influencing our alertness and directly shaping our states of mind. You can pick up brainstem signals at any time by becoming aware of shifts in your breathing and heart rate– and also by paying attention to arousal itself.

Think of times when you realize you’re feeling drowsy. You are focusing on the brain’s alertness, noticing your capacity to attend to information– a teacher’s lecture, for example, or this book you are reading. Perhaps you’ve returned to the same paragraph several times without taking it in and you’re ready to admit that you are not in a state of mind to continue reading. You then choose how to respond: Should you have a cup of coffee or splash cold water on your face to try to wake up, or should you just take a nap? This is one way you regulate your internal world– by being able to monitor and then modify energy and information flow, in this case, levels of brainstem arousal.

The brainstem also works with the limbic area and cortex to assess safety or danger. When our threat- assessment system tells us we’re safe, we let go of tension in our bodies and our facial muscles relax: we become receptive, and the mind feels clear and calm. But with an assessment of danger, the brainstem (along with the limbic and middle prefrontal areas) activates a decision tree: If we think we can handle the situation, we enter the fight- or- flight state of alert. This in turn activates the sympathetic branch of the autonomic nervous system (ANS). Our heart begins to pound as the body readies for action. Adrenaline pours into our bloodstream and the stress hormone cortisol is released; our metabolism is prepared for the energy demands ahead.

On the other hand, if we believe we’re helpless, that there’s nothing we can do to save ourselves, we freeze or collapse. Researchers call this the “dorsal dive,” referring to the portion of the parasympathetic branch of the ANS that has been activated. This response goes back to our earliest evolutionary ancestors, and it’s thought to have real benefits for an animal that is cornered by a predator. Collapse simulates death, so an attacker that eats only live prey may lose interest. Blood pressure drops precipitously in a freeze state, which could also reduce blood loss from wounds. In any case, it makes the animal or person fall limply to the ground as they faint, which maintains precious blood flow to the head.

If you are vertically integrated, you can read what your body is telling you about your safety or danger, including signs far more subtle than running away or fainting. You may feel a certain tension when you’re walking down the street and only then realize that someone is following you. Or you get a feeling that you just can’t trust the person you’re talking with. In everyday life, having access to subcortical energy and information is also essential to thinking. Being aware of these subcortical impulses enables you to know how you feel, alerts you to your needs, helps you prioritize your choices, and then moves you to make a decision. This is how “gut sensations” or “heartfelt feelings” help us live our lives fully.

Since Anne had little interoceptive awareness, these subtle signs of safety, danger, or threat were probably muted or missing from her awareness as well. But even without awareness, these threat states, these brainstem- mediated neural shifts, can directly influence our thinking, our reasoning, and our sense of vitality. Someone can be ready to fight, vigilant for danger, or depleted by a sense of helplessness without knowing why. I thought Anne’s palpitations might be in some way related to internal stress states. If a subtle internal or external threat led to adrenaline and cortisol release, her heart would pound, which would capture her attention– but since she had little consciousness of her internal state, or of its causes, she wouldn’t know why it was pounding.

LIMBIC LANGUAGE: “PRIMARY” VERSUS “CATEGORICAL”

I’d been struck repeatedly by how confused Anne seemed when I asked her basic questions about how she felt in a particular situation. The cutoff seemed to extend to her relationships. She’d told me outright that she had few friends and no connection with her family. Staying away from her family as a child– and now as an adult– seemed self- protective, but I was concerned about the rather distant way she talked about her own daughters. They were the same age she’d been when she banished feelings from her life, and I knew that however “independent” children that age sometimes act, they do indeed need their parents.

In her first session, Anne had told me that her life was empty. Yet her refrain of “too busy” also conveyed that it was full to the brim in some ways. What seemed to be missing was the sense of energy and engagement that can give even ordinary experience richness, depth, and meaning.

To open the channels of vertical integration in Anne, to bring the signals of her body, brainstem, and limbic areas up into her cortical awareness, I first needed to open the doors of “emotional communication” between us. But when we talk about emotional communication, what do we actually mean?

If we focus only on the easily named and universally recognized emotions– such as anger, fear, sadness, disgust, excitement, happiness, or shame– we can miss the real richness of our minds: the realm of what I call “primary emotion.” Primary emotion is the subtle music of the mind, the ebb and flow of energy and information that we sense during the moment- to- moment shifts in our internal state throughout the day. Sometimes, against this constantly shifting, changing background, an event occurs that orients our attention and activates our arousal, and the intensity of our arousal creates within us an emotion such as anger or fear. Even though these universal (or “categorical”) emotions are recognized worldwide, in every known human culture, they do not emerge as often as you might think. Consider the course of a day. How often do you experience clear, unambiguous anger or fear? For most, it is rare. Yet your inner world is filled with subtly textured, constantly changing states– what I am calling “primary emotions”–that continually color your subjective sense of being alive.

Thinking about these primary and categorical emotional experiences opens a new window on how we connect with others– and with ourselves. Young children need attunement with caregivers to feel seen and safe in the world. As parents, we can attune not only to our child’s outbursts of categorical emotion– such as sadness or fear– but also to primary emotional states such as being energized, alert, focused, sleepy, or subdued. Parents who wait for a categorical emotion to arise before they “connect emotionally” with a child are missing the majority of important opportunities to attune. Attunement with a child’s primary emotions is available moment by moment, as we pay attention to whatever has captured her attention. We can also tune in to our child’s internal world by noting her levels of arousal. Is she engaged or depleted, lively or subdued? Having this primary emotional attunement to our children helps them feel deeply connected to others; as we resonate with them, they feel part of a larger “we.”

Learning to track internal states– to become aware of our primary emotions– is a refined skill that begins when we’re children and continues throughout our lives. Sensing this internal flow of energy and information is the essence of mindsight. As we first learn to pay attention to this flow through the attention our caregivers pay to us, we enter the world of knowing the mind. But Anne was not given the opportunity to learn how to sense her internal world from a safe, secure place after losing her mother and her grandparents. She, like so many of us, had to find a way to cloud her mindsight lens so as not to see her inner world. She learned to live a life devoid of meaning.

THE FEELING OF MEANING

Meaning is literally shaped by the limbic regions’ appraisal process– the continual and immediate sorting of experience into “relevant or irrelevant,” “good or bad,” “approach or avoid.” This, along with input from our middle prefrontal cortex, helps create the meaning of events in the brain. Meaning has a feeling to it, and establishing vertical integration for Anne would allow her to become receptive to this textured sense of significance coming from her inner world.

The cortex, especially in the frontal areas, can create abstract representations without input from the direct experiences mediated by the subcortical areas of the extended nervous system. We can think of the word flower but never sense the flower’s aroma. We can paint that flower on canvas, but never lose ourselves in its textures and colors. Even right- mode visuospatial images can be sterile when devoid of access to subcortical input. There are musical virtuosos who leave audiences cold, literary scholars who are unmoved by the poetry they write about, physicians who diagnose but cannot connect with their patients. Integration requires openness to allow the many layers of our inner world to enter our awareness without rigid restrictions.

Words themselves are abstract representations that emerge like islands from a sea of associated meanings. Take, for example, the word daughter. If I say “daughter” to a young woman who’s just heard the news that she is pregnant, that word will initiate a cascade of associations and responses. All sorts of beliefs may emerge: Daughters are fun. Daughters fight with their mothers. Men prefer sons. Will the pregnancy bring all the joys of her own relationship with her mother– or the pains of disappointment and confusion? Washes of sensation may fill her mind until she feels overwhelmed, unclear, cloudy. Maybe having a daughter would not be so good; maybe she’d be a better mother to a son.

With the word daughter, all of the young woman’s own developmental history may be activated and revisited, with a mixture of old and new emotions. Was she close to her mother? Did she find her own voice, or did her mother overpower her? Taking on her mother’s perspective, she might wonder how her mother felt about having a girl. How did she respond to her daughter’s adolescence? Were her responses supportive or hostile or perplexing as she as a young girl matured physically, transformed from teen to adult, became sexually active, left home? And now that she is joining this passage of women from one generation to the next, how will her mother respond to the news of her pregnancy?

The meaning of daughter includes all of this and more, including the emotional associations that might arise if the young woman were to happen upon a mother- daughter pair at the park who appeared to be in rapt connection, exhilarated by each other, their laughter contagious yet private.

Now think of what mother meant to Anne. How could she stay open to her cascading associations, beliefs, concepts, developmental issues, and emotions? These elements of meaning, the architecture beneath our wash of feelings, would naturally flood her mind, intrude into her relationships, dis- integrate her brain. What choice did Anne actually have? Could she say, “Oh, no problem– let me be aware of this pain of loss of my mother. Let me be aware of this intolerable humiliation from my stepmother.” Not possible. And so Anne discovered a survival mechanism: She cut herself off from meaning in her life. But while this was useful as a defensive maneuver in her childhood, it had become a fence that imprisoned her, cutting her off not only from herself but from her own daughters. Anne felt nothing and she was stuck. She had “a meaningless life.”

THE FENCE OF DEFENSE

When strong primary feelings emerge or a particular categorical emotion arises, we may respond with an ingrained, learned reaction that is rooted in our past. If you grew up in a family in which anger was expressed as destructive rage, for example, you might get incredibly anxious whenever anger is expressed. In response to that anxiety, you may have learned to feel helpless and confused, causing you to freeze; or you may have learned to be fearful of rage, causing you to burst into tears and flee the scene; or perhaps you learned an aggressive “fight” response, causing you to meet anger with your own anger. Fight, flight, freeze– these are all emotional reactions to, yes, your own emotional responses.

Beyond our learned reactions to ordinary emotional threats, we also have patterns of adaptation that help us cope with overwhelming situations and with our reactions to them. These patterns of adaptation are sometimes called “defenses” and they shape the matrix of our personality: how we experience our inner world and interact with others. Here is the outline of the common pathway of defenses that is now accepted by many psychologists: An emotional response arises ➔ creating a reaction of anxiety/fear ➔ which initiates a defense. This defensive reaction shuts down the emotion, or at least the awareness of it, which then lowers the anxiety/fear and allows us to continue to function. This is why defenses are not only useful– they are often essential.

Defenses come in many forms. We can rationalize intellectually about a situation, minimizing awareness of our feelings by moving away from the more feeling right- brain mode into the logical left. This was Stuart’s strategy. We can attempt to ignore a situation, skewing our perception to see just the positive side of an experience, a kind of “selective neglect.” Some simply call this optimism, and it is a time- honored, and sometimes even healthy, strategy. When you are surrounded by lemons, make lemonade. Some people deal with a painful feeling by “projecting” it onto others and then hating them for it. This primitive and destructive adaptation is called “projective identification,” the strategy that says the best defense is a good offense.

Whatever the defense, the idea is the same: We build a fence around our awareness so that we don’t feel the anxiety or fear associated with feeling our feelings. These are usually automatic strategies, patterns of reactivity adopted without conscious intention or even recognition, and certainly without free will or choice. Anne’s orchard “decision” was in fact an unusually conscious, perceptive moment of self- reflection. It was only later that her intentional suppression was transformed into automatic repression. During her childhood, Anne had no way to soothe her profound internal distress and interpersonal pain and so she could not remain open to their meaning, and her adaptation was to just “go cortical.” Once she had blocked vertical integration, the primary function of Anne’s body was to transport her head.

ATTENDING TO THE BODY

Anne and I were now at our fourth session, and I was able to pre sent to her a plan for therapy based on our initial period of assessment. As a physician, she was intrigued by the notion that her adaptation at age eleven might have persisted as a neurological pattern in her brain. I also told her that I thought she had been through a lot in her early years, and that I thought I could help her deal with whatever that time meant for her.

Anne and I needed to go on a journey together to help her feel receptive, to be attuned to herself, so that she could open up her awareness in new ways. She was up for the task, not certain what any of this would involve but willing to commit to a few months of therapy to find out. That was a good place to start. I told her, as I’d told Jonathon, that we’d need time to alter her synapses so that she could unlearn her old patterns and create new ones. Awareness, I went on, was the “scalpel” we would use to resculpt her neural pathways. Anne was intrigued by that image and wanted to know more. Now I knew I had captured her attention– the first step in changing her mind, and her brain.

I didn’t want to distract her with the details of how awareness might enhance neuroplasticity, but I had some recent research in mind. The nucleus basalis, part of a region adjacent to the brainstem, has neural projections that secrete the chemical acetylcholine throughout the cortex. Acetylcholine is a neuromodulator, and its presence enables any neurons that are activated at the same time to strengthen their connections to one another. One theory suggests that we can use focused awareness to stimulate the nucleus basalis to secrete acetylcholine, thus enhancing neuroplasticity and learning. If this is so, it helps to explain why paying close attention gives our minds the power to change our brains.

All I told Anne was that through the work we would do she’d discover for herself the power of attention. We went over the basic mindfulness- of- the- breath exercise and we practiced some walking meditation.As we’ve seen with Jonathon’s experience, learning mindfulness techniques can strengthen the hub of the mind so that internal sensations, such as bodily signals or waves of emotion, can be experienced with more clarity and calmness. My hope for Anne was the same, that with practice she’d strengthen the very parts of her brain that could not yet permit her to feel her feelings. She was game for taking on these forms of practice, not only in the office but as a daily “mental training” regimen at home. A weekly therapy session, an hour at a time, wasn’t enough to focus her attention in an intense way. She would need regular synaptic exercise between her sessions with me. Reinforcing new synaptic linkages requires repeated neural firing to stimulate neuronal activation and growth– to SNAG her brain.As with Stuart, we could use the focus of attention to stimulate the activity and growth of areas that had been underdeveloped in childhood. In Anne’s case, these regions would be the important circuits of interoception and self- regulation– of sensing the inner world and regulating that world– that had not been given the opportunity to grow well in her youth.

At her next session, I suggested we do a body scan, like the one I did with Stuart, thinking it would help her to gently become aware of her body in a nonthreatening way. I asked her to close her eyes and to look inward. Anne was fine as the focus of awareness moved up from her feet to her legs and then to her hips. I felt cautious as we progressed to the pelvic area. Anne had told me she hadn’t been abused sexually, but this is one point at which anxiety sometimes emerges strongly during a scan. Anne focused with no problems. We then moved to the abdomen and the back, and she was still fine.

But when we focused on the chest, she started to breathe rapidly. Her hands started to shake. She made fists and pushed down with her forearms on the arms of the chair as if she were trying to hold down some feeling. Then she opened her eyes wide and said that she had to stop– she was hyperventilating and looked terrified. Anne had jumped from rigidity straight into chaos.

I was concerned that Anne was having a panic attack. We stopped the exercise and continued our session with her eyes open, and her agitation gradually subsided. She said she didn’t want to discuss the experience. She was “fine” now; she simply ” didn’t like the body scan.” We’d wait till later, when she’d developed more of an internal reserve to deal with upsetting sensations, to come back to that important source of bodily information. While research suggests that focusing attention on the heart can trigger both physiological reactions and an awareness of intense emotions, the specific nature of the feelings it had awakened in Anne was not yet clear. As our work continued, I hoped we’d learn more.

BUILDING INNER RESOURCES

The direct body- scan approach had triggered so much anxiety that Anne panicked, so I needed to choose more gradual ways to introduce her to body awareness. I started our next session by asking her simply to notice the movement of her fingers as she slowly opened and closed her palms. “Just noticing that,” I said, “let yourself be filled with how the hand appears, and how it feels.” We repeated the walking meditation, too, letting her feel the sensations of her feet with her eyes open.

Next I suggested that we develop a “safe place” into which she could always retreat– an image in her mind that she could draw upon to soothe herself whenever uncomfortable feelings arose. At first Anne had trouble coming up with an image. I told her this could be something from memory– a special vacation spot, her favorite room at home– or it could be entirely imaginary, a place where she could imagine herself being peaceful and contented, or at least safe and secure. Anne finally recalled a cove at the beach near her medical school. “I used to go there just to be with the waves,” she said. “The sound of the waves, how they moved in and out, the curve of the beach, the sunny skies– everything gave me a feeling of things being okay.” I asked her to sit with the image of the cove for a while, soaking in the sights and sounds and sensations. Then I told her to just notice her body and asked how that felt. When she said, “It feels good,” I went on. “Being aware of the body, just sense whatever arises in your experience.” I wanted her to create a neural association between her mental image of a place of safety and her awareness of bodily sensation.

This technique is used in several schools of body- focused therapy, and it had an entirely different purpose than the imagery work I’d done with Stuart. By creating that connection, Anne was able to experience and articulate what her body was feeling. She told me her abdomen felt soft, her face relaxed. Then she said her breathing was easy. She could feel her heart and it was “calm and steady.” In contrast to her reactive panic during the body scan, Anne was now experiencing a state of receptivity. We were harnessing her regulatory prefrontal areas to help monitor and manage her internal states.

Another receptivity- enhancing technique I use involves systematically tensing and releasing the individual muscle groups of the body, from feet to head, which helps create a state of relaxation. Still others involve bilateral stimulation, whether by listening to alternating sounds or gently tapping on the left and right sides of the body. Some researchers believe that this creates not only relaxation but also increased sensitivity to mental imagery. But Anne felt most comfortable with her image of the cove and with the breath-awareness exercise I’d taught her first. We continued to practice them to give her confidence that she could go from reactivity to receptivity by her own mental efforts.

I wanted to keep her experience in the body on the positive side, so next I suggested that we try an exercise with color that evokes different feeling states. I do this work with a set of eyeglasses that have lenses made in various colors. Color is a powerful emotional cue for many people, but in Anne’s case I asked her to focus on sensations in the body itself. Again, this seemed like a safe way– for some patients it’s even a playful one– to awaken her awareness of shifts in physical sensation. With the first pair of glasses– green– nothing happened. “I don’t feel a thing …just the usual…just blank.” But when she put on the second pair– these happened to be purple– she exclaimed, “Whoa– this is weird!” Anne said she had a “tingling feeling right up here,” pointing to her upper chest.

After that, Anne felt her body change with each new color. Red evoked energy in her limbs “like ants running up my arms”; blue a deflated feeling in her abdomen “like a hole”; yellow a sense of constriction in her throat. This was not a test– each person has a unique response. The point was simply to create contrasting sensations, so that Anne could begin to recognize internal shifts.

Anne’s initial response was excitement at her newfound ability, and we spent a good part of the session with the glasses, just letting her experiment with this neutral approach and find words to describe her body’s sensations. But when I suggested that we might return to the body scan next time, she became frightened and hesitant. “I don’t want to get into a panic again,” she said, bringing her hand protectively to her heart. “Those feelings are not right…I can’t handle them.”

I reminded her that she now had her safe place as a resource at any time, and I assured her that we would move slowly. The internal world of Anne’s childhood had been beyond what she could tolerate– at that time. Now she might be surprised to find that she could learn to tolerate what had once been intolerable.

WIDENING THE WINDOW OF TOLERANCE

Personal change, both in therapy and in life, often depends on widening what I call a “window of tolerance.” When that window is widened, we can maintain equilibrium in the face of stresses that would once have thrown us off kilter.

Think of the window as the band of arousal (of any kind) within which an individual can function well. This band can be narrow or wide. If an experience pushes us outside our window of tolerance, we may fall into rigidity and depression on the one hand, or into chaos on the other. A narrow window of tolerance can constrict our lives.

In our day- to- day experience, we have multiple windows of tolerance. And for each of us those windows are different, often specific to certain topics or certain emotional states. I may have a high tolerance for sadness, continuing to function fairly well even when I or those around me are in deep distress. But even a lesser degree of sadness– whether your own or others’–may cause you to fall apart. In contrast, anger may be relatively intolerable for me; a raised voice may be enough to send me right out my narrow window. But for you, anger may not be such a big deal; you see a blowup as a way to “clear the air” and move on. In general, our windows of tolerance determine how comfortable we feel with specific memories, issues, emotions, and bodily sensations. Within our window of tolerance we remain receptive; outside of it we become reactive.

By now you’ve probably noticed that the window of tolerance matches the river of integration, which I introduced in chapter 4. The more freely that river can flow and the farther apart its banks are, the better we can attain and maintain integration and coherence. But if that flow is constricted, we’re constantly in danger of hitting the banks. In many cases our well- being depends on widening the window of tolerance so that we can hold the elements of our internal world in awareness– without being thrown into rigidity (depression, cutoffs, avoidance) or chaos (agitation, anxiety, rage). As we develop mindsight, our windows of tolerance widen and we can experience the fullness of our lives with more acceptance and clarity.

If we move through life without mindsight, we may keep narrowing our window of tolerance around a specific emotion or issue. Then we may find ourselves either bursting the boundaries of that window and jumping into the chaos of reactivity, or avoiding situations that trigger such ruptures, restricting our lives without knowing why, not giving ourselves the freedom to escape our rigidity and empowering ourselves to grow. To widen our window, to make ourselves more adaptive and at ease with a particular feeling or situation, we need to change the associations that are embedded in the neural networks themselves.

“STAY WITH THAT”: THE HEALING POWER OF PRESENCE

The presence of a caring, trusted other person, one who is attuned to our internal world, is often the initial key to widening our windows of tolerance. Because Anne did not have such relationships in her later childhood, her tolerance for awareness of bodily sensations and primary emotions had narrowed. Cutting off access to her sub-cortical input was once a means to survive– but now it was restricting her life. If I could be present fully with Anne, if I could let my own internal world resonate with hers and remain open myself, I could help her track her sensations and uncover their meaning, widening her windows of tolerance.

Recall that the resonance circuits include mirror neurons that would enable Anne to resonate with my own reactions to her. My being present fully with Anne at moments of distress could help her mirror my own inner feelings of safety. Here is a key fact about relationships: The resonance circuitry not only allows us to “feel felt” and to connect with one another, but it also helps to regulate our internal state. (It is the middle prefrontal area at the top of the resonance circuitry that shapes our subcortical states.) In other words, the interpersonal resonance between Anne and me could help widen her window of tolerance, so she’d feel safe enough to feel her own feelings. This is how in the moment, face- to- face, we help one another grow, and initiate the long- term synaptic changes that help us even when we’re apart. And by continuing with her internal reflection practices at home– the mindfulness- of- the- breath and the walking meditations– Anne could further reinforce these synaptic changes, transforming the way she communicated with her own body.

At the beginning of our next session, I once again invited Anne to return to the body scan that had triggered her panic. It had now been ten weeks since our first session; during this time she had been doing her home practices regularly, and she and I had developed a trusting and collaborative relationship. Exercises such as the safe-place imagery and the colored glasses had helped her observe her inner world in a more objective and accepting way. She had also received a clean bill of health from her internist, who had rechecked her heart and found nothing of concern physiologically. Still, I moved into the body scan slowly, giving her plenty of time to immerse her awareness in the subtle sensations from her lower limbs, her hips, her abdomen.

When we came to her chest, her panic began to emerge. She grimaced and her left hand went to her chest. She opened her eyes and said we had to stop. I reminded her that whatever that sensation was, she always had her breath awareness and her internal safe place to return to. If she felt herself getting too close to the edge, she could shift into a focus on her safe- place imagery of the cove and watch the waves go in and out for a while. She closed her eyes, focused on her breathing, and her face slowly relaxed. She opened her eyes again, looking right into mine, and said, “Thanks.”

I suggested she might take a few moments and just let this new sense of openness fill her. As her body seemed to settle into the chair, and I saw her hands relax and her face become more supple, I said that she might just notice how she could use the focus of her attention to calm her body, and her mind.

Anne said she was “ready to dive in” and we went back to the body scan. When she focused on her chest region, the panic again began to emerge, but this time she said she could now sense it from a “more distant place.” She had learned that she could just stay with her sensations, and that not only could she be “okay,” the sensations themselves would change and become less overwhelming.

That’s the strange thing about panic– when we lean into it, it loosens its grip on us. The power of reflection allows us to approach, rather than withdraw, from whatever life brings us. And when we learn to “stay with” a feeling, to give it its time in awareness, then we discover that feelings– even very strong and threatening feelings– first arise and then dissipate, like waves breaking on the shore. Panic is just another feeling, a set of neural firings in our brain. Learning to stay open and present to it, or to any other distressing feeling, is not easy, but it is an essential step in moving through the fences of defense.

THE WISDOM OF THE BODY

What was revealed as Anne learned to confront and regulate her anxiety, as she widened her window of tolerance? What sensations, images, feelings, and thoughts were now free to emerge? As we returned to the body scan during that session, Anne felt a wave of coldness in her chest and tightness in her limbs. Again she said it was hard to breathe. She spent a few moments at the cove, following her breaths as if they were waves on the shore, she later told me, and then said that she could continue.

As she stayed with her inner experience, images of her father and stepmother appeared in her mind’s eye. She felt frightened of their faces and wondered if this panic was a fear of their meanness, of how they had mistreated her. She again focused on her breath to ground her in the hub of her mind, that open and receptive state of her regulating and self- soothing prefrontal cortex.

Now Anne began to tremble, her face looked tense, and tears began to flow down her cheeks. “I see a picture, but it’s not something I remember…it’s something I’ve seen, something I have. It’s the only picture I have, the only thing I have left. It’s a picture of me and my mother.” Anne opened her eyes and looked at me. “I have that picture buried in my closet somewhere– I haven’t looked at it in years.” She seemed relieved but exhausted. It was near the end of our time, and I asked Anne if she’d like to just take a few moments to sense her breath, to let her body relax and her mind appreciate all that she’d been through during this session.

To make sure we had thoroughly explored her heart- mediated feelings of distress, we returned to the body scan during our next session. Anne’s initial sensations of panic shifted gradually during the scan. She now began to feel a heaviness in her chest and a tightening in her throat. Then tears filled her eyes. As her panic was allowed to take its natural course, unhindered by defensive reactions, it moved toward completion, dissipated, and revealed an emotion that had been far more hidden in Anne, a profound sense of sadness. Now the essence of staying present for Anne was to allow these sensations of loss and grief to unfold in their own time.

In a subsequent session we simply sat together as she let the image of her mother holding her– the one in the photograph she’d remembered– fill her awareness. At first her tears were slow, a few drops she didn’t seem to notice and did not wipe away. But as we stayed together with whatever she was feeling, she began to sob uncontrollably, her body bent over as she moaned in pain. I let her sense our connection with my own nonverbal signals– a sigh, a quiet “ummmm,” the rhythm of our breathing in synch. When she opened her eyes and we looked at each other, I noticed my own tears.

“I know this sounds strange,” she said, looking at me now with softer eyes than I’d ever seen in her, “but I can feel my mother’s presence; I know she is here somehow with me.”

Then Anne told me she had had a dream the night before our session. “I haven’t had a dream in decades,” she said, “and this was a strange one.” Dreams are the work of sleep, one of the important ways we integrate memory and emotion. They occur when cortical inhibition is released enough to allow our subcortical limbic and brainstem regions to have a heyday with imagination and feeling. The dream itself is an amalgam of memories in search of resolution, leftover elements of the day’s events, sensory inputs while we’re asleep, and simply random images generated by our brain’s wild activity during the rapid- eye- movement (REM) stages of sleep.

I thought it was a great sign that now, finally, Anne’s subcortical regions were sending their input into her dreaming brain– enough for her to remember these internal images when she awoke. I listened closely.

“In the dream I am swimming to shore but the tide is going out and I can’t fight it. Then my legs are tied to a boat that is headed out to sea, but I keep trying to get back. I’m pulling frantically with my arms, but I’m getting more and more exhausted. The boat just keeps moving and I can’t see the shore anymore. I woke up this morning and felt panicky. It was awful.”

I asked her to tell me more about what she’d felt when she awoke, and what came to mind now as she recounted the dream to me.

“I don’t know. I think it’s weird. Maybe I’m just too tired.”

But a week later she described a second dream, and also the notes from the therapy journal she’d begun to keep. “I’m back in the water. Now I can see the shore. But the boat is moving again– I’m going quickly out to sea. I feel like I’m going to drown for sure. But then I reach down to my leg– I think I really did, it felt warm– and I pulled off the ropes. I freed my legs and started kicking like mad. Finally I got to the shore and collapsed in the warm sand. I remember just looking up at the sky, seeing the sun, and feeling safe. Then I woke up and knew it was all a dream, but I felt relieved.”

This time she was more ready to talk about what these images might mean for her, and we explored her feeling of helplessness as she was pulled away from everything that was warm and solid in her life, and then her relief as she finally reached the shore again.

IMAGES OF HEALING

At the beginning of our next session, Anne handed me a large envelope. She had found the picture of her with her mother, which had been taken when Anne was about two years old. She told me that after her father remarried, he had destroyed anything that reminded him of her mother, and had never spoken about her. It was only after she’d left for college that she was finally able to visit her mother’s parents, who gave her this photograph.

But in the envelope there were two pictures, an old snapshot and a larger print of the same image. Anne had scanned the old photo into her computer and then deleted the figure of her father, who had been “lurking” in the background. “I want to hold on to the part of memory that gives me warmth,” she said. “I don’t need to be tied to my father’s mean wife, or to his grief.”

The enlargement centered on little Anne and her mother, nestling together in an old- fashioned wing chair. Anne was in her mother’s lap, pointing excitedly toward the camera with her right hand, while her left hand held on to her mother’s encircling arms. Her mother was gazing down at her and smiling. It was a moment suspended in time, the child secure in her mother’s embrace yet eager to reach out, the mother delighting in her daughter.

As I handed the photos back to her, Anne said, “I can see a certain sadness in her eyes.” Her mother’s cancer had been discovered when Anne was about a year and a half old. “I can only imagine how horrible that was for her, knowing she wouldn’t be able to care for me, or see me grow up.” We sat together, just staying with that feeling of clarity.

In the weeks ahead, Anne would also come to reflect on how difficult it must have been for her father– her grandparents had told her how much he had loved her mother, and how he’d fallen apart when she died. “I guess he did the best he could after she was gone,” she said to me one day. “He was so young himself, only twenty- six. But I still can’t understand why he just disappeared– and why he chose such a monster for his new wife. When my mom died, in many ways so did my dad.”

Anne’s grief was finally taking its natural course as she opened to all of her feelings– love, loss, confusion, anger, and even forgiveness.

Anne decided to stay in therapy beyond the few months she had committed to originally. As her work continued, Anne’s life began to have a sense of vitality that had been missing for decades. She began to take time to exercise regularly. Her palpitations gradually reduced in frequency, then ceased altogether. She started to see some of her colleagues socially, outside the office. She also found the time to “just be with” her daughters, and she discovered that there were things they enjoyed doing together (it turned out that the girls liked art projects, too). Instead of catching up at the office every weekend, she made it a point to plan outings with them. “I know they won’t be around much longer,” she told me.

Anne feels more present in the room now. She holds herself differently; she seems at home in her body, her movements more fluid and relaxed. She has started to wear her hair down, flowing over her shoulders. And she has told me that she no longer feels empty inside.

Purchase Mindsight at the new, all-Daniel Siegel section of the WTCI Bookstore.  Find Dr. Daniel Siegal online at drdansiegel.com.