In an Unspoken Voice

by Peter A Levine

  Last, but by no means least, a fourth biological function of immobility is that it triggers a profoundly altered state of numbing. In this state, extreme pain and terror are dulled: so if the animal does survive an attack it will be, even though injured, less encumbered by debilitating pain and thus possibly able to escape if the opportunity arises. This “humane” analgesic effect is mediated by the flooding of endorphins, the body’s own profound morphine pain-relief system.21 For the gazelle, this means that it will not have to suffer the full agony of being torn apart by the cheetah’s sharp teeth and claws. The same is most likely true for a rape or accident victim.22 In this state of analgesia, the victim may witness the event as though from outside his or her body, as if it were happening to someone else (as I observed in my accident). Such distancing, called dissociation, helps to make the unbearable bearable.

  The African explorer David Livingstone graphically recorded such an experience in his encounter with a lion on the plains of Africa:

  I heard a shout. Startled, in looking half round, I saw the lion just in the act of springing upon me. I was upon a little height; he caught my shoulder as he sprang, and we both came to the ground below together. Growling horribly close to my ear, he shook me as a terrier does a rat. The shock produced a stupor similar to that which seems to be felt by a mouse after the first shake of the cat. It caused a sort of dreaminess in which there was no sense of pain nor feeling of terror, though quite conscious of all that was happening. It was like what patients partially under the influence of chloroform describe, who see all the operation, but feel not the knife. This singular condition was not the result of any mental process. The shake annihilated fear, and allowed no sense of horror in looking round at the beast. This peculiar state is probably produced in all animals killed by the carnivore; and if so, is a merciful provision by our benevolent creator for lessening the pain of death. [italics mine]23

  While Livingstone attributes this gift to his “benevolent creator,” one need not invoke “intelligent design” to appreciate the biologically adaptive function of diminishing the sharp edges of serious pain, terror and panic. If one is able to stay broadly focused and perceive things in slow motion, one is more likely to be able to take advantage of a potential escape opportunity or think of an ingenious strategy to evade the predator. For example, a friend of mine told me about a time when he was withdrawing money from an ATM for an international trip. As he turned from the machine, a group of thugs grabbed him, holding a knife to his throat. As in a dream, he serenely told them that it was their lucky day, and that he had just withdrawn a lot of money for a trip he was taking the next day. The astonished muggers calmly took the money and slipped away into the darkness. I am sure that some degree of dissociation helped him to survive his ordeal without being so terrified as to be unable to strategically deal with this dreadful situation.

  Indeed, the adaptive and benevolent value of dissociation is illustrated by another riveting tale, this time by the adventurer Redside, from the jungles of the Indian subcontinent:

  [He had] stumbled when crossing a swift stream, dropping his cartridge belt into the water … now out of ammunition, he noticed a large tigress stalking him. Turning pale and sweating with fright, he began retreating … But it was already too late. The tigress charged, seized him by the shoulder and dragged him a quarter of a mile to where her three cubs were playing. As he recalled it afterward, Redside was amazed that his fear vanished as soon as the tigress caught him and he hardly noticed any pain while being dragged and intermittently mauled while the tigress played “cat and mouse” with him for perhaps an hour. He vividly remembered the sunshine and the trees and the look in the tigress’s eyes as well as the intense “mental effort” and suspense whenever he managed to crawl away, only to be caught and dragged back each time while the cubs looked on and playfully tried to copy mama. He said that, even though he fully realized his extreme danger, his mind somehow remained “comparatively calm” and “without dread.” He even told his rescuers, who shot the tigress just in time, that he regarded his ordeal as less fearful than “half an hour in a dentist’s chair.”24

  Although Livingstone and Redside appeared to be surprisingly unscathed by their unpleasant encounters with predatory cats, Livingstone nonetheless developed an inflammatory reaction in that shoulder that broke out for the rest of his life on the anniversary date of the attack. Unfortunately, for many traumatized individuals, such dissociative reactions or “body memories” are not minor and transitory, but lead to a wide variety of enduring, so-called psychosomatic (physical) symptoms (which might aptly be called “somatic dissociation”25) as well as to an inability to focus, orient and function in present time—in the here and now. While traumatized humans don’t actually remain physically paralyzed, they do get lost in a kind of anxious fog, a chronic partial shutdown, dissociation, lingering depression, and numbness. Many are able to earn a living and/or raise a family in a kind of “functional freeze” that severely limits their enjoyment of life. They carry their burden with diminished energy in an uphill struggle to survive, despite their symptoms. In addition, we human beings, who cleave to symbols and images, may continue to see (in the mind’s eye) ourselves at death’s door long after the real danger has passed. A vision of the mugger or rapist holding a knife at your throat can endlessly recycle itself, as though it is still happening.

  How Biology Becomes Pathology

  Although the states of immobilization and dissociation (like those just described by Livingstone and Redside) are dramatic, they do not necessarily lead to trauma. Even though he didn’t develop any limiting fears, Livingston did exhibit a localized anniversary reaction on his affected shoulder. In the case of my accident, I notice that I am now a bit more cautious when crossing streets—especially in Brazil, where I often teach, and where moving vehicles can be a considerable challenge to pedestrians. Otherwise, I don’t exhibit any type of fear or anxiety reaction in respect to traffic. Perhaps my friend who was robbed is also a little more careful about going to an ATM at night. But neither my friend nor Livingstone nor Redside nor I was traumatized; though we undoubtedly experienced arrest, terror, immobilization and dissociation. Speaking for myself, I feel (and friends have confirmed) that I was actually made stronger and more resilient by successfully navigating my accident and its sequel. My friends noticed that I seemed more grounded, focused and playful.

  This brings me to the central question: what determines whether acute exposure to a (potentially) traumatizing event will have a long-term debilitating effect as in posttraumatic stress disorder? And how does understanding the dynamics of the immobility response postulate clinical solutions to this crucial question?

  Let me reiterate. Generally, an animal in the wild, if not killed, recovers from its immobility and lives to see another day. It is wiser but none the worse for wear. For example, a deer learns to avoid a certain rock outcropping where it was ambushed by a mountain lion. While my observational hypothesis is based on field observations and is not empirically proven, my interviews with wildlife managers throughout the world have supported it. In addition, it is difficult to imagine how individual wild animals (or their entire species, for that matter) would have ever survived if they routinely developed the sorts of debilitating symptoms that many humans do.b This natural “immunity” is clearly not the case for us modern humans … but why and what can we do about it?

  Long-Lasting Immobility

  As I was completing my doctoral dissertation at Berkeley in 1977, I continued with my daily visits to the musty stacks of the graduate library, where I stumbled upon the critical key in my understanding of trauma. This article by Gordon Gallup and Jack D. Maser informed the central question of how the normally time-limited immobility response becomes long-lasting and eventually unending.26 For their work, I would like to make a personal nomination for them to retroactively receive the 1973 Nobel Prize in Physiology or Medicine—along with the three ethologists previously mentioned.


  In a carefully thought-out and well-controlled experiment, the authors demonstrated that if an animal is both frightened and restrained, the period during which it remains immobilized (after the restraint is removed) is dramatically increased. There is a nearly perfect linear correlation between the level of fear an animal experiences when it is restrained, and the duration of immobility.27 When an animal is not subjected to fear before being restrained, immobility generally lasts from seconds to about a minute. This spontaneous capacity is called “self-paced termination.”28 In dramatic contrast, when both repeatedly frightened and repeatedly restrained, the experimental animal may remain immobilized for as long as seventeen hours!

  It is my clinical experience and understanding that such a robust potentiation has profound clinical implications for the understanding and treatment of human trauma. I shall discuss how the “potentiation,” or enhancement, of immobility by fear can lead to a self-perpetuating feedback loop causing an essentially permanent quasi-paralysis in the traumatized individual. This condition, I believe, underpins several of trauma’s most debilitating symptoms, especially numbing, shutdown, dissociation, feelings of entrapment and helplessness.

  A few years ago, in Brazil, I had the opportunity to observe the interaction between fear and immobility within a laboratory setting and thereby gained direct verification of the seminal work of Gallup and Maser on tonic immobility. Although there are very few researchers in this important field, I found one actively involved in experimental animal research on tonic immobility at the laboratory of Leda Menescal de Oliveira at the Federal University, School of Medicine in Ribeirao Preto, Brazil. Her work has focused on the brain pathways activated in tonic immobility.29

  Leda and her group were exceedingly generous in sharing their time and expertise. During my visit I was able to directly observe and participate in the experimental methodology of earlier researchers whose written work had inspired me in the 1970s. These experiments carried out in a dimly lit room involved gently picking up a guinea pig, holding it securely, turning it upside down, and then placing it on its back in a V-shaped wooden trough. When this is done without a struggle, the experimental animal lies motionless for seconds to a minute or two, then flips over and calmly walks off in self-paced termination from immobility. The laboratory guinea pigs may have some inherent fear of humans (a possible confounding variable). Yet these animals still appear to come out of their immobility relatively quickly, and aftereffects were not apparent, thus presumably nonexistent or very mild.

  A vivid illustration of self-paced termination comes from the arts. In the play Picasso at the Lapin Agile,c the young Pablo takes the jacket from the pretty young woman he has brought up to his Paris loft. Coolly executing a seductive ruse, he reaches outside the window to where a white dove is perched on the ledge. Slowly, but without hesitation, he firmly takes the bird in his hands. As he turns it over, the bird ceases all movement. He then drops it to the street, three stories below. The young woman gasps, reflexively bringing her hand to her mouth. At the last moment, the dove rights itself and flies off, unharmed, into the Montmartre night. Picasso then turns to his voluptuous human prey, drawing her immobile body into a lecherous embrace.

  This is an instructive glimpse of how animals negotiate immobility and how the consensual sexual act and orgasmic release involve some immobility in the absence of fear. Immobility, in the absence of fear, is benign and even pleasurable, as in the example of a mother cat carrying its limp kitten securely in its mouth.

  Returning to the laboratory: Self-paced termination clearly does not occur when an animal is purposefully frightened before being captured (or when it comes out of immobility) and/or is repeatedly placed on its back. In the latter case, the guinea pig (or other animal) remains paralyzed for far longer than a few minutes. When this fear-induced process is repeated numerous times, the animal remains immobile for a significantly longer period—so much so that we went out for lunch and returned to find it still inert on its back.

  Applications to Trauma Therapy

  Only a handful of behavioral scientists have been seriously interested in tonic immobility as the biological foundation of trauma. Some of these recent authors have suggested that immobility is intrinsically traumatic.30 It is my experience that this view is misleading. It limits our understanding of trauma and restricts the possibility of effective therapeutic intervention. My clinical work with thousands of clients has confirmed that immobility can be encountered with or without fear. Indeed, I believe that it is only when the immobility becomes inextricably and simultaneously coupled with intense fear and other strong negative emotions that we get the entrenched trauma feedback loop in the form of persistent posttraumatic stress disorder. My experience, beginning with Nancy (in Chapter 2) and then working with so many more traumatized clients, has taught me that the very key to resolving trauma is being able to uncouple and separate the fear from the immobility. However, before returning to animals, I shall consider the studies of two observant individuals: the neurologist K. L. Kahlbaum and the fictional detective Sherlock Holmes.

  As one of the earliest pioneers to scientifically study tonic immobility in humans (which he called catatonia), Kahlbaum had it right when, in 1874, he wrote, “In most cases catatonia is preceded by grief and anxiety, and in general by depressive moods and affects aimed against the patient by himself.”31 He is saying, I believe, that both immobility and a significant exposure to fear or grief need to occur for (transient states of) tonic immobility to be converted to a paralysis/self-induced depressive feedback loop—that is, to a state of chronic catatonia, or (arguably) posttraumatic stress disorder.

  Sherlock Holmes, the very epitome of a careful and precise observer, seems to confirm Kahlbaum’s perception in the story of Mr. Hall Pycroft: Holmes says to Watson, “I had never looked upon a face that had such marks of grief … and of something beyond grief … of a horror, such as comes to few men in a lifetime. His brow glistened with perspiration. His cheeks were of the dull dead white of a fish’s belly and his eyes were wild and staring … He looked at his clerk as though he failed to recognize him.”32 Such a combination of wild agitation, deathly white complexion and frantic dissociation (staring wide-eyed as though without recognition) accurately describes acute human fright paralysis. While traumatized individuals may not exhibit all of these characteristics all of the time, they do form the undercurrent of traumatic shock as PTSD.

  The few psychologists who write about tonic immobility (TI) as a model for trauma seem to agree that both fear and restraint (or, at least, the perception that one cannot escape) are required to induce TI. Here I am in full agreement. However, in a recent excellent review article, Marx and colleagues33 add, “Everything we know about the animal and human literature to date suggests that the TI response may itself be traumatic.”d It is here that I respectfully differ: my clinical experience forces me to part ways from that speculation.

  After more than four decades of observing my traumatized clients à la Holmesian discernment, and guiding them out of frozen states of terror and horror, I have found that the dynamic elements of fear, tonic immobility and trauma paint a far more complex and nuanced portrait. I am convinced that the state of immobility is not in and of itself traumatic. When, for example, immobility is induced in non-traumatized subjects through “hypnotic catalepsy,” they frequently experience that immobility as neutral, interesting or even pleasurable. Mammal mothers routinely pick up their young to move them about, and those babies, when in the clutches of a loving mother’s jaws, stop squirming and go limp. Also, during sexual congress, and particularly at orgasm, the female of many mammal species becomes immobile at this pinnacle of pleasure leading (arguably) to an increased likelihood of fertilization. Contrast this to trauma, where intense fear (and other strong negative affects), when coupled with the immobility response, becomes entrapping and therefore traumatic. This difference suggests a clear rationale for a trauma therapy model that separates fear and other stron
g negative affects from the (normally time-limited) biological immobility response. Separating the two components breaks the feedback loop that rekindles the trauma response. This, I am convinced, is the philosopher’s stone of informed trauma therapy.

  Marx and colleagues do seem to amend their position in a direction more compatible with mine when they suggest that “for clinical purposes, it may matter less if TI among humans is an ‘all or none’ phenomenon, as the intensity of the TI response among humans may be an important factor in the onset and maintenance of posttraumatic psychopathology.”34 Questions like this exemplify important areas for interdisciplinary discussion. Indeed, one of the impediments to the progress of truly effective trauma therapy has been that clinicians, experimentalists and theoreticians have not worked in ongoing partnerships to address such pivotal questions.

  To summarize: It is my observation that a precondition for the development of posttraumatic stress disorder is that a person is both frightened and perceives that he or she is trapped. The interaction of intense fear and immobility is fundamental in the formation of trauma, in its maintenance and in its deconstruction, resolution and transformation. I shall elaborate on the therapeutic implications of this relationship in Chapters 5 through 9.