Dear NESTTD Members and Supporters:

As I sit down to write the last column of my two-year term as President, there is so much I want to say and so little time to say it. Rather than being just a duty that goes with the office of President, these columns have become a welcome forum to share with all of you the things that I usually share only with a few close colleagues and myself. So I find myself asking, "What haven’t I said? What important issues or clinical experiences could I share?"

Having just come back from the annual meeting of the International Society for the Study of Dissociation in New Orleans, I could report on the excitement of seeing our own members making their mark as part of a national organization: Girvani Leerer spontaneously volunteering to help set up on Friday; Laurie Brown in attendance as she is every year; Audrey Wagner, Jim Chu, Rhonda Sabo, Joanne Twombly, Deirdre Fay, and myself giving presentations on a variety of topics. (We are very sophisticated about trauma and dissociation in our community here in New England, and it is wonderful to be able to appreciate that fact when we are participants at the national level!) On the other hand, rather than giving you "headlines" from the conference, I could talk about how our field and our national organization have changed—and how they have not! But I think instead I will take this last opportunity to mount my soapbox and talk about the issues that are closest to my own personal heart.

The theme that probably comes up for me the most, day after day and week after week, is best summarized by the words of Rachel Yehuda at last year’s BU Trauma Conference: "What does it mean to ‘treat a trauma’? Does it mean to ‘treat’ the incest? or does it mean to ‘treat’ the low self-esteem?" It has only been in recent years that we have begun to ask this question. Prior to then, the assumption in our field has been that treating trauma means treating memory, that we have to help the patient "get it out" or, as we now say, to "process" it. But my patients have always taken a different view: they have been willing to treat the memory if that was the only route to wholeness, but they have been wanting simply to feel safe in their bodies, safe in the world, connected to others, and worthy of care and respect.

As I listen to them and watch them gradually and painfully gather back strength and life, I have been struck by their intuitive wisdom, their "knowing" of what they need. Over and over, I have witnessed that what consistently "breaks the chains" of post-traumatic bondage is simply "presentification" and "personification," to use the terminology of Onno van der Hart, Ellert Nijenhuis, and Kathy Steele. When the survivor can "own" the trauma and neglect as sadly but truly his or hers, rather than "disown" it via the defensive maneuvers of avoidance, dissociative disconnection, re-enactment, and self-loathing, she or he has achieved personification: "It really did happen, and it happened to me, and this is the effect it has had on me." When post-traumatic neurobiological hyperarousal or distorted cognitions or hypervigilence or anger and grief no longer are confused with responses to present daily life but instead are understood as unfortunate aftereffects of the trauma, then the survivor has achieved presentification: she is present in the here-and-now rather than perpetually re-living the past, aware of being symptomatic perhaps but not caught up day after day in a "long, slow flashback" that she interprets as her "present."

I am reminded of a former patient of mine, "Peggy," and a conversation I had a long time ago with her adolescent self. This angry, mistrustful, despairing teenage part of her kept insisting that the husband was not to be trusted, that being a mother meant that you were harming your children instead of helping them, and that she would always be one of those "dirty kids from across the tracks" in the eyes of the world. I remember assuring her that she might be very surprised to know what could be different now: now that there was a grownup part of her, now that she could choose who and what to be, now that she was in control of her life. Peggy and that teenage part of her were very skeptical, of course. Although Peggy had had a rush of memories and knew her story, she did not yet understand how it was hers. She could intellectually understand but not take in emotionally that her fear, shame, and despair were byproducts of that experience; she could not "own" her frightened, compliant child self nor her angry, hypervigilent adolescent self. There were no places in her life when all of her selves could find common ground—until two things happened: she took up tennis and responsibility! Taking up tennis was a connection to her childhood history of athletic ability: it was a resource that she could develop now and thereby right a past wrong, and it was an avenue for the angry, mistrustful teenager to reinstate compromised defensive responses each time she met the tennis ball and sent it back across the net rather than being hit by it. The responsibility was that of being the best mother she could be to her children, even though she "hated" being a mother. As she deliberately cultivated empathy and connection with her children, she "grew" her own ability to feel safe giving to and receiving from others, including her husband. The final piece of presentification was provided by the fruits of both the responsibility and the athletic achievement: she became an accepted and admired member of a wealthy tennis-centered community, and she did it in a way that quite literally put the pieces together! She openly acknowledged "where she came from:" admonishing her friends to not to forget to give generously to needy children and families and joking that her outspokenness came from "taking the girl out of the street but not the street out of the girl."

When I asked Peggy at this point in her life whether she would like to alleviate more of her PTSD symptoms using EMDR, she was adamant! "No way! I am in the present now: why would I ever want to go back to the past?" When I explained that the anger, anxiety and depression she still periodically experienced could get better if we processed the memories, it did not pique her interest: "When I get those feelings, I just know that I’m in the past, and I have to do something to get back into the present—that’s a small price to pay for leaving those memories behind."

So that is the question I raise for all of us to think and talk about: is Peggy "right"? Or are the experts "right"? Can trauma survivors learn to befriend their residual PTSD? Or learn to live with it as one might live with diabetes or some other treated but still chronic illness? If they successfully (even if not completely) treat the self-esteem issues, the hyperarousal, the hypervigilence, and the phobias of intimacy, change, and having a normal life, then is that not enough? If they feel reasonably safe in their bodies and have in some way brought completion to the unfinished past, is that not enough?

Thank you for listening to my soapbox philosophizing and for sharing these dilemmas with me,

president@nesttd.org