TU117: Resilience Trauma and the Brain W/ Guest Bruce Perry MD, PhD

So in order to help the brain kind of basically reorganize and kind of have to do exactly what you said. Go back and go start with these lower systems, help them become as organized as they can and then move up to systems that are mediated in the middle part of the brain and then all that they move up to things, you know, reading, writing, speech and language and so forth. And the irony is most of us approach these kids that have these complex development problems from the top down. Hey, everybody. Hey, everybody. Welcome to Therapy Sensor. This is a podcast that breaks down interpersonal science into practical and understandable tidbits. And as you listen, I can just imagine little light bulbs of insight appearing above your head. You're going to be surprised and touched at what you learn about yourself as you get more accurate and in-depth view of your mind and your heart. And as you figure out those close to you. Therapist Uncensored brings you decades of experience with interpersonal psychotherapy, relational neuroscience, modern attachment, and anything else they think will be helpful in healing humans. Now hear your co-host, Dr. Ann Kelly, and Sue Marriott. Hey, those of you guys that have been listening to Therapist Uncensored know that we bring you the very best of the best of the sciences related to modern attachment theory, relational neuroscience and trauma. And we are really proud of this and today is no exception. We're very excited to bring you Dr. Bruce Perry. He's a senior fellow of the Child Trauma Academy. He's also adjunct professor in the Department of Psychiatry and Behavioral Sciences at Northwest University School of Medicine in Chicago. He's also co-author of the best seller, the boy who was raised as a dog. And he also wrote, "Born for Love, White Empathy is Essential and Endangered." Actually, he's quite prolific. He has the author of 300 journal, articles, book chapters, scientific proceedings, and he has won many, many awards, including the T. Barry Braselton Infant Mental Health Advocacy Award and the Award for Leadership in Public Child Welfare. His career has spanned over the last 30 years in a variety of ways, all of which bring together the best of the neurosciences and how to make change, how to facilitate change in real people. He's been an active teacher, clinician, researcher, and children's mental health and the neurosciences. He was on the faculty of the Department of Pharmacology and Psychiatry at University of Chicago and he was the chief of psychiatry for Texas Children's Hospital. He's also been featured on everything from NPR, the Today's Show, Good Morning America and Nightline. Every news channel that you can imagine, no kidding, Oprah Winfrey, Dateline, NBC, 2020, BBC, basically just about everywhere. There have been documentaries based on his work. And in the print media, they've also highlighted some of his research, including a Pulitzer Prize winning series in the Chicago Tribune, US News and World Report, Time Newsweek Forbes, Washington. New York Times and Rolling Stone. This work has been instrumental in describing how childhood experiences, including neglect and traumatic stress, change the biology of the brain and therefore the health of the child. Without further ado, we bring you our conversation with Dr. Bruce Perry. I thought we would jump in with a concept that is a very desirable thing that people are interested in, everybody wants and we want to impart it to kids and especially our own kids, which is this concept of resilience. Could you say a little bit about your thinking about resilience? Yeah, you know, people use the term resilient or refer to resilience and what we know from a lot of neuroscience research and a lot of research and developmental psychology is that resilience is a capacity, basically the capacity to tolerate stress, sores and challenges and maintain function. And that this capability is something that is built, you know, people used to think that children were born resilient and it's probably better to think about a child being born malleable that their response up to their environment. And then through experiences, particularly early in life through relationally mediated experiences of moderate challenge where there's predictability and there's consistency and some degree of controllability. Your stress response systems become stronger and more capable, more flexible, more resilient. And then as you face stressors, you can essentially deal with them, but resilience is something that can get tapped out. And so if you are someone capable of demonstrating resilience and your life, all of a sudden falls apart, people in your life just drift away and you are in a chaotic, violent, overwhelming environment, your resilience gets tapped out. And so part of what I think is happening now in the field is that we're trying to help people better understand how do you create resilience building opportunities and how do you minimize resilience dissolving experiences, which are basically what people refer to as adversities and unpredictability. What would you say, like it's possible, like you said that to certainly be overwhelmed the child and have too many of these, you know, you're going to drop out. But is it, is there a model or is part of this model that you could have not enough stressors so that that's another way of disabled child? One of the fundamental principles of neurobiology is something we call neuroplasticity, which is really referring to the fact that these neural networks are changeable. And at the core of that principle is that neural networks are only changeable if the neural network itself is activated. And so really what that means is if you want to make your stress response systems more flexible, strong, capable, and resilient, you have to activate your stress response systems. In other words, you only become resilient by being stressed, but you become stressed in a certain pattern. And the three things that are part of that pattern of stress activation that build resilience are predictability, moderation, the stress is moderate and controllability. So if those elements are present in an experience, you are building resilience. Let me give you a simple example. A little child who maybe shy is in a classroom where every week you have to stand up in front of your peers and recite two lines from a poem. And so the first time this child does that, it's really right on the edge of an overwhelming stress. But they get up and they, you know, they're voice cracks and they worry about it all day long and they do it and they succeed. And they know that next week they're going to have another one and the week after that they have the other one. And there's elements of controllability because they can practice, they can practice, it can practice. It's predictable because they know it's going to happen and it's moderate. And so what happens is if they do that every week by the middle of the holiday break, this child will not only feel less distressed by getting up and reciting in front of peers, those two sentences, they'll feel more comfortable in other public speaking situations. And by the end of the year, they will not only tolerate that, they might enjoy getting up and demonstrating confidence when they recite their lines. This is the kind of thing that happens, you know, you hope this happens in a good school environment, right? You take a child, you give them a moderate predictable dose of challenge because they're exposed to novelty, but it's a big enough dose that they can tolerate. They go out and leave their comfort zone, they don't blow up, you know, they get distressed, they demonstrate some level of mastery and then they go back to their comfort zone. Those are resilience building things. If you are applying the musical instrument, you have your recital coming up, you know, that's a resilience building experience. If you do sports and you have competition, that's a resilience building experience. And again, that's the kind of thing that we want to provide for our kids to help them deal with something like, you know, a school shooting, which is an unpredictable, uncontrollable, overwhelming experience. And long behold, when you look at it, what you find is the kids who've had these resilience building experiences cope with those unpredictable extreme events in a superior way, you know, over time, they don't have long term symptoms that are disruptive and so forth. Yeah, it makes me think of the prepare the child for the path, not the path for the child, equip. And, you know, what about upper middle class kids with very active parents, are you seeing this where the stimulation and the risk is too low that there's an overprotectiveness? Yeah, well, definitely, you know, anybody who does clinical work is going to run into a family that they know that we'll have a kid who might have school refusal or be an anxious kid. And one of the things that we're seeing is that if you are a helicopter parent and you are essentially, whenever your child is in a challenging situation, you're making sure that they don't get too overwhelmed, you do their homework for them, you don't let them climb on the monkey bars. They literally don't have opportunities to have these moderate stressors, these challenges, and they end up having an extremely difficult time coping with the increasing complexity and demands that are going on taking place through development. So a classic example of this in my, you know, I do a lot of work with kids would be where I hear you have a helicopter parent with a toddler and then all of a sudden the parent decides that well, now it's time for the child to go to school. And you go from a situation where the parent is always there, never lets them sort of explore, never lets them get anxious or uncomfortable, and now they drop them off with a bunch of strangers in a complete unknown situation and leave and the child panics, and it's because there has been a misunderstanding about what we refer to sort of as dosing and spacing, which is in our estimation, that's sort of the critical element in successful therapy and successful education is understanding. Dosing and spacing. Oh, that's fantastic. I think that is a great example and I can think of many, many others like the launch of kids in the college and the difficulty there. You know, we hear the same thing about kids going to college that they just are unable to deal with and then of course, at that age, they have all kinds of self regulating alternatives, you know, they'll smoke pot, they'll drink too much, and that leads to a different set of problems. And then we hear from our colleagues in the corporate sector that this is happening with people who leave college and go out into the corporate sector that they're literally, they're having people who had a lukewarm or neutral job review after the first six months, and they'll get a call from the parent. Seriously, there's, there are companies that have hired people in their personal department to manage parent interactions of employee parent interact. You know, if you're listening out there that have kids, this is really a listen up because this is so true and, you know, we always talk about prepare the child for the path, not the path for the child, but the here you're hearing it, what the actual consequences are, and this is an underdeveloped stress response systems, I think you talk quite a bit about. I wonder if we go back a little bit and think and if you'll speak to us a little bit about the developmental model and the neuro sequential model that you have, yeah, if we could start there and then we'll see about how we can apply that going forward, if that's okay. Well, many, many, many, many, many, many, many years ago when I was entering my clinical training as a psychiatrist, I was coming out of the world of developmental neuroscience, I was trained at a PhD in neuroscience and have been studying development of these key stress response systems in the brain. And I entered the clinical world and immediately was kind of did what I was told, I was a good boy, I would see a child and then my supervisors would say, all right, you get out your green book back then it was a green book, it was the DSM three. And look up what quote the child has that was like, oh, okay, and I never, I don't think once I had a child who sort of fit into one category thing. And I started to realize, wow, you know, at some point, we've got to start thinking about what's going on underneath the behavior, where did this come from? Why are they inattentive or why are they struggling? Why does intimacy scare them? You know, all kinds of things that I was seeing, I was always wondering why. So I started to take the things that I knew from neuroscience and think about the clinical problem through that lens. And it became clear to me that a lot of the problems, at least with the children I was working with at that time, were related to a misunderstanding about what they were capable of doing. That they were eight years old chronologically, but developmentally in social domains, for example, this kid would be like a two year old. If you have a two year old, if a set of sort of eight year old expectations for a two year old performer, you're going to have a big gap between capability and expectation, which leads to these misunderstandings. And I started to realize it, wow, you know, if we just sort of take this eight year old and give the child a two and a half year old set of expectations socially, the child succeeds great. They'll master that two and a half year old social stuff. And within three months, they're going to be able to tolerate three year old social expectations. And so we started this, I started this way of thinking about doing clinical work to basically try to get an understanding of cognitively, where are they? Are they on track age wise or are they kind of behind cognitively with regards to regulating themselves? Is this more like a toddler or is this more like a 14 year old? And then when I spend a lot of time doing education for the teachers and the family about, you know, listen, if you just understand what happened to the child developmentally, you'll recognize that they have the social skills of a two year old because they've only had the social learning opportunities. That a typical two year old would have. It's not that there's anything wrong with them. I mean, they literally, if you give them the opportunities that are developmentally targeted, there's every reason to believe they can catch up. But if you continue to have expectations that are unrealistic, you're just going to drive them into the ground and you're going to get frustrated. They're going to have bad self esteem. They're going to avoid any interaction with you and, you know, the whole thing is going to be a mess. And so when we started to do that, we had some success. And from that, really, this neuro sequential approach started where we have tried to integrate some of these concepts about development or science into clinical practice and in the way you do your clinical problem solving. And we're still working on the model. And I think it's, we've had some nice success with it, but it's still an early, early phases of a development. So can I say it back to you, kind of how I understand it, just to see, you know, if I'm getting it and also so folks can hear it again. The general just is and you all, you all actually have tools and stuff to map the neuroscience, but that you look at a child developmentally and the sequencing part of it is that you always have to start from the bottom up. So whatever the developmental piece that's the oldest, the youngest or however you want to say it, right, the oldest part of the brain, the youngest of the child, that there's no skipping steps, you know, without causing other problems. So that you match them where they are from the bottom, in a way, and then you're able to layer skills on top of that. So then the therapy does change as they grow up developmentally. Exactly. You know, one of the things that, and again, I don't want to get too technical about this, but the brain as it develops, and I think everybody knows that the brain has multiple regions that what we know about the brain is that as you go from the bottom of the brain to the top, it gets more complex. And the top parts of the brain are the parts of the brain involved in thinking, speech and language, abstract cognition, that's the cortex. And the lower part of the brain are the brain stem that is involved in regulating respiration and body temperature and blood pressure. Some people talk about it as the ritulian brain and, you know, so forth, but the thing that's really important about this going back to the whole issue around stress and resilience is that there are these really, really important core regulatory networks that originate in the lower part of the brain. And everybody's heard of them, Norpen, Efron, Dopamine, Serotonin, and there are some others, but collectively these networks reach every part of the body. They go out through the on and off nervous system, they go up through the neuroendocrine system, and then they go upstream into every part of the organizing brain. And so early in life, if these networks have any kind of disrupting impact, you know, intrauterine alcohol, intrauterine distress for the mother, lack of oxygen while you're in utero, there will be sort of a disorganization to those systems. And then because they play a major role in the upstream organization of top parts of the brain, you'll get this cascade of problems that originate from these earlier disrupting experiences. And so part of what we do see is that you'll have kids that are being parented by wonderful parents in a great school and they'll have regulation problems. They can't pay attention, they sort of have fine motor issues because they can't pay attention and they're in pulse of still, they end up with social problems and then learning problems, and there's this cascade of issue. And then they'll accumulate these DSM diagnoses, ADHD, conduct disorder, whatever we end up calling them. But if you look at the origin of the problem, it's because these corregulatory networks were abnormally organized, really early in life. And then we don't always know what it why. So in order to sort of help the brain kind of basically reorganize, kind of have to do exactly what you said, go back and go start with these lower systems, help them become as organized as they can and then move up to systems that are mediated in the middle part of the brain and then ultimately move up to things, you know, reading, writing, speech and language and so forth. And the irony is most of us approach these kids that have these complex developmental problems from the top down, you know, if they have a speech and language problem, we send them to a tutor for their help them with their other things. And it's not as if you shouldn't do that. It's just that if you do that while these lower systems are still dysregulated, you're going to have a really frustrating experience. You're going to be adding stressor, which is not going to help the stress response system. And also thinking about kind of the different disciplines and, you know, the psychoanalytic, editable and pre-edible, you know, sort of that's a way of thinking sort of a sequencing. So there's a lot of therapists now, you know, with somatic experiencing and body oriented work. It's funny. I'm just kind of just occurring to me that I thought of that as a model and, you know, different people are attracted to that model related to how they're trained and things like that. But really that model is particularly good for some of what you're talking about about the bottom up and not necessarily everybody needs that because they may have been checking along just fine and then had something happen later. Yeah, so I hadn't really thought of like the different, you know, insight oriented, somatic experiencing offer, I'm thinking of adults, really are hitting different parts of the brain. Right, exactly. And it's interesting. I'm glad that you are talking about that because this neurosequential model that we use is promiscuous with regards to intervention. And it really just depends on what the assessment says. So if the assessment says just like you point out if they've got pretty well organized sensory integration and regulation, but they have terrible relational capabilities and self-esteem problems and the possibility issues related to cortical development will focus on more on relational and cognitive or insight oriented work. We have a lot of kids and we've got, I think somewhere near 65 or 70,000 assessments all across the world now that have been using this model. And now it's particularly useful for kids that have these really complex and adults that have complex trauma related things, but we also use it with lots of other populations. And so we'll have many, many people who the recommendation will be, you know, you really should talk to somebody, you know, you need to be with a traditional sit in my office, insight oriented talk therapist. Now a lot of just because of the sampling issue that with our clinic, most of our kids are, as you pointed out earlier, they're maltreated, they've been exposed to trauma, they've got these complex presentations. We frequently, frequently will start with a more body, somatic sensory integration, OT, guided process. And then as they get regulated to a certain point, then we'll add in more relationally focused stuff, which in example might be kind of a play therapist that knows how to do non directed play therapy. But ultimately that leads into, let's talk about strategies and let's think about things and let's look, you know, let's do insider cognitive work. And so we have kids that we work with for five or six years, where we'll have gone from these very somatic sensory things all the way up to more, you know, traditional TV, trauma focused cognitive behavioral therapy and organ set or in work. Yeah, it makes me think of, you know, how many of us adult therapists working with adults, you know, that if you're not somatically trained, you know, you start out with, how do you feel? And these complex questions that really require, again, the scaffolding underneath. So how would someone in the adult world or a therapist that's listening kind of apply some of these ideas? Is that too complex or is that? No, no, that's, I mean, we actually have a couple of very big clinical groups that are using this predominantly with adults in San Mateo County, for example, they've been using this in their adult mental health, outpatient clinics. We have the largest inpatient psychiatric group or setting in the Netherlands is using the nursing, which a model. And because of the work that we do with kids who are maltreated, almost all of their parents have developmental needs themselves. And so a lot of the places we work with will do work with the parent and the child, you know, both of them having had one of these neuro sequential assessments. And really what it amounts to is that it all depends on the assessment, right? So if you do an assessment and you find out that you've been working with somebody and they continue to have some form of fundamental self-regulation problem. And they've been using all kinds of maladaptive ways to self-regulate, you know, and they might be cutting or it might be, we want to help you first of all understand why we think there's your using this, you know, maladaptive way of regulating yourself. We view it as a form of regulation. We might be wrong, but that's kind of what we think the role that serves for you. And we think that we'll never get rid of it unless we can replace it with healthier forms of regulation. Now, I don't use medications very much. I can, but I don't. But what I do is say, listen, when you feel really crappy, what do you do? And somebody will say, you know, I go to my room and I take out my drawing pad and I draw. Or some people will say, you know, I just get on and play video games and some people will say, you know, I just go for a long walk. And what you find is that there's a lot of healthy forms of self-regulation that people use, but they don't dose them in the right way. They don't really understand the power they have. And so what we do is we sit down with them and say, all right, listen, here's your day. We believe that if you took five minutes every hour and did some drawing, you know, get your lap will watch out. And if you don't want to draw, just draw, even if you don't want to get up and walk, just go walk. And we begin to put together basically a daily regulatory plan. And they may have two or three options. You know, they may find you somebody who really likes to ride their bike or they like to swim. And we'll just find something to create a regulatory plan. Because one of the metrics we have is this weekly map of win during the day, they even have an option to do anything regulatory. And it's amazing how many of us adults literally have huge blocks of time during the day, where we don't do anything to regulate ourselves in a healthy way. You know, we'll sit. And that doesn't surprise me actually at all. You can totally see that and relate to that. If you're interested to be productive, doing these regulatory things actually makes you more productive. And so you sort of have to reassure people that listen, I know it sounds crazy, but instead of working for 60 minutes in a row, if you actually got up every 15 minutes and walked for four minutes, you'd get more done, even though we're taking 12 minutes out of your hour. And once people start doing it, they get hooked. The three principles were predictability, spacing, pacing. When we talk about spacing and dosing, the dose could be anything you dose. It could be the dose of lifting weights, right? But when you think about lifting weights, the dose would be 35 pounds. And the space between the pattern of lifting 10 times, you might rest 90 seconds, and then you lift 10 more times. And then there's the other spacing, which is you only do that three times a week. So you give the muscle consolidation time. And so we think about therapeutics in this way too. We actually think that meaningful therapeutic moments where you're really sort of connecting with a person are very brief. And so you can have an adequate dose of therapeutic connection that's literally five seconds long. And those of you who do therapy know exactly what I'm talking about. There are moments in your office when you will look at that person, and they'll look at you, and you'll both be in the same place, and they'll feel that you care for them, that you're trying your best to understand them, that you're going to be there, and they feel it. And that five second dose of intimacy will sustain them for a long time. You're right. It's like we have to have something to talk about in order to get there. But if there was some way to short circuit that, yeah. This interpersonal interaction that you have in therapy really requires that you're in the right space before you can have the expectation that they're going to get in the right space. And so if you're not capable of being regulated yourself and capable of sort of putting everything away and being fully present in that moment with that person, those moments aren't going to happen. Everybody knows what it's like when you sort of realize you got back to back appointments and you've got another point. The ability to sort of calm yourself down and be truly there. That's hard to do. One of the things that we find that helps the people that we work with is that we have them yoke some sort of somatosensory regulatory activity with the talk. So a lot of people will walk they'll go for a walk with the client and I'll sit on a bench and there'll be a moment, you know, there have these different moments. And so if you are in parallel with somebody, it makes it easier for them to be intimate with you than if you're going to raise your face with them. This is of course one of the reasons why analysts have people somebody sit on the couch and you're you're not looking at the analyst while you're sort of doing this really intimate mind. This is very different than a lot of people feel comfortable doing, you know, a lot of people, you know, the clients first of all may not want to be seen walking down the street with a shrink. But you know, there's a lot of variations to that too, even just in the office, like, like moving, standing, yeah. We use a lot of that kind of pattern, repetitive, rhythmic stuff to help facilitate the process of regulation for both parties. And totally see how as the client experiences control over that it's predictable that there's a real soothing that is the bottom up soothing to then be able to open their hearts or open their minds. If you think about reproach mine and those of you who sort of are trained is you'll remember the whole description of a toddler who feels safe at home base with primary care or mom, let's pretend. The trouble is out and it starts to explore being separate and the further they get away from mom, the more sort of anxious they get, but it's tolerable stress. And it's a dose of controllable stress or and they try on independence and then they tolerate it for a little while and then they come back and they get to home base. The primary is exactly the opposite process is that they're trying on intimacy. They're over here where they feel safer and they kind of leave their comfort zone and see how they can try on intimacy with you. And at five seconds when it happens and those of you who do therapy, you know that when you first meet someone and you start the process, the first few sessions are just kind of dancing around trying to figure out. And then they'll get a little bit closer and see how they can how long they can stand there and then they'll go back and then maybe you'll have a session where they really do get really close and then the next session they won't show up. Well, that's the regulatory system that they're regulating the intimacy and we're giving them that power to do that. You know, I read somewhere you had said something about using for yourself visualization early in your career and I've gotten really interested in this. There's a model, the ideal parent protocol where that, you know, rather than just relying on the therapist, this is a very brief description, but you teach the client to really let themselves imagine the perfect response and the ideal response from a parent figure, not your own parent, but you can be anything or anybody. And that has seemed to have some very powerful results because then you can carry that with you and it's not just the one person. Does that seem like that sort of fits with the way that you're thinking about how people grow and heal? Absolutely. I mean, I think that you're probably also familiar with the research that's been done on the ability to build empathy by reading novels. And the same thing is I know it sounds crazy, but the same thing is true of kids watching cartoons by literally putting yourself into the superhero role of being powerful and then generous helps literally influences the way your brain orders. Yeah, Alan Alda from Mash was one of their internal to cure figures. So it totally makes sense. Absolutely. And it's, we do that with a lot of, in a lot of ways. And so I do think that if you are able to do that sort of internal mind wandering where you're creating, we all create an internal world where you play some role. I think part of the trick is, and this is something that I learned a long, long time ago, because I started doing it really when I was an athlete. Is a lot of people don't realize that you can actually have more control over that internal process of imagining than you realize. So for a lot of us, it just kind of happens where like you find yourself thinking that you're like a superhero. Yeah, you can actually intentionally set yourself up into a scenario. And we've used this a lot. This kind of guided imagery for sport, but we've also used it with people at PTSD to actually put them back into a situation and have them experience it in a controllable, more moderate way. So we've talked about this controllable, moderate activation of the stress response as a resilience building activity. But it's also, if your stress response system is sensitized and overactive, those same elements are going to take your stress response system and make it less sensitized. So therapeutic is what a moderate dose of activation of the stress response is for a Vietnam vet, you know, remembering a traumatic event is so small. I mean, it's, you know, it's not 45 minutes, it can't stand 45 minutes. It's just a millisecond image where they'll they'll be able to tolerate it. But if you help them learn how to do this on their own, they can have controllable times. In fact, I've given, you know, little note cards and timers that once an hour, you got to look at this note card and this is your cognitive narrative of what happened. And you have to get out and you have to read it, go through it until you just go, that's too much and put it back in your pocket. And that might be five seconds, you might get through 30 seconds, you might get spent a whole minute thinking about it, but you have to do it. And so it literally creates these controllable, predictable doses and they determine what's moderate by, you know, how they feel. You know, literally control, RIS enough. And that I believe is your definition of trauma, right, which is that it's anything that impairs that stress responses and that it causes damage to it that then sets it up to either over and to respond. Yeah. You know, it's interesting. I don't know if I backed off using the language of trauma because as you know, I mean, it's sort of like the term love. It means something different for everybody. One of the things I try to talk about with regards to this and this is that when there's a school shooting or a natural disaster or really bad thing, everybody can kind of wrap around your head. Wow. That really is a bad thing. And I can see where that could cause trauma. What people are having a hard time wrapping their head around is, how is it being a minority kid in a majority culture, hundreds of microaggressions. How is that going to result in a sensitized stress response system that's a form of trauma, part of what I've been doing when I teach is that this is. So I've shifted off the language a little bit that in the same way that there's this pattern of moderate predictable activation of the stress response leads to resilience. Anything that activates the stress response system in an unpredictable or a controllable way, whether it's extreme or not, is going to lead to this sensitized overly reactive stress response system. So that means being marginalized, you know, being an out person in an in population, and it could be that you're the gay kid in the neighborhood. That you are an African American kid in a in a white school, it could be that you're the the creed child who's going into Edmonton and go to school there. And so racism and other isms have the capacity to create the same physiological impact on the stress response has a major capital T trauma. So it's such an important point. I really like you distinguishing that and including that. And I think of, you know, the resting heart rates, for example, and a securely attached African American child, the cortisol levels of on waking are already affected. And it's exactly what you're saying. And these are kids that wouldn't say that anything's wrong that they wouldn't even know that they were anxious. They're continually experiencing. And part of this has to do with the complexities of sort of neuro sociology to something you guys talking about a lot of this podcast, but human beings are contagious. We have this neurobiology where we're continually reading and responding to the nonverbal cues of others and a lot of it's unconscious. And so you can get a person who looks at you, like you don't quite belong here without saying anything overtly racist to you. Where your brain will go, wait a minute, uncontrollable little activation. This happens all day long. Now, so many people who are of color will tell you that they can give you dozens of little examples of how that plays out of the course of the day. But those of us who are sort of in the majority were so oblivious to this most of the time. We don't understand what it's like to be a kid in a class where you raise your hand and they never ask in Sally. Every time Sally raises her hand, she gets to answer the question. I did it a few times. They don't ask me, so I'm just not going to do it anymore. And again, it's just not conscious. There's not an awareness. An example of that for me is that I'm gay and I have had kids way before it was cool. Like my kid is already now in college and kind of didn't think about it. It had been in a liberal environment. So we go to province town for a big event where that basically everywhere you look, there were gay people, right? And it just became for a moment, it became the norm. And I remember seeing somebody on the subway. It was a heterosexual couple and they looked terrified. You know what I mean? They were the ones sitting really stiff and look really scared. That flip was really interesting. And then on the plane flying back, that was the only time I could actually feel it. Where I began to feel the consciousness of touch that I was scanning for safety and it was just an okay environment. And I knew that I would lose. I knew I would forget it because it would just become so normal, but it was only through the contrast. I think that's a great example because I think most of the time I would guess that you even said it that you live in a liberal community, but I'll bet you get dozens and dozens of little looks, like at school events or whatever. And you just may not even register anymore. And also this gets back to this thing, like passing and not passing, again, whether it's race or gender or what have you, but the more that you are an obvious other or that you're claiming that the stress response goes up. Now I'm curious, we can't talk about stress just really quickly. So as a neuroscientist, how do you think of the attachment scientists and an attachment and adult attachment? I've talked about this a lot, actually, and I've published with electronic part of what is so important. And again, this is an interesting thing because the attachment world is a rich source of information for the trauma world, which has almost ignored attachment stuff. Unfortunately, but there's no doubt about it that the early relational experiences are the major determinants of the set point for the stress response. And it is the quality of the caregiving that literally helps build in the capacity to be resilient or sensitized. They go hand in hand, you know, there's a thing that we talk about we teach about in this model that in context of early caregiving, the attentive attuned responsive care is essentially building into the brain, a triune association between the reward neurobiology of the brain, the stress response neurobiology and the relational neurobiology. And those three things are woven together in a healthy way, you've got an incredibly strong, capable child, you're going to be able to basically deal with stressors and benefit from all kinds of other positive things. And it all happens in context of the child getting dysregulated, hungry, thirsty, cold, they cry out, here comes the caregiver, fundamentally meets their needs, decreasing the distress, any distress leads to pleasure. So the reward neurobiology is activated while you're relieving physiological distress and the brain is bombarded by all the relational cues of the smell, the sound, the touch, movement of the interaction. And so these things get woven together, regulation, reward and relationship. Wonderful. And earlier, I think before we got on just to make this point to one of your focuses has been really like even enter you to in how the brain, I think you said 20,000 neurons a second at some portion of prenatal development. And then you know, it slows down, but that we continue to be able to neuroplasticity goes to the grave, I think, but generating actually new neurons. So I guess if you'll speak a little bit about just even in that small window, you know, prenatal to five, the changes that happen. The brain, I think as everybody has probably heard a million times, is explosively growing early in life. And in utero, it's like almost beyond comprehension. As you mentioned, there are periods in the third trimester where you make 20,000 random neurons per second. That's just crazy. It really is almost incomprehensible. Yeah. And then after birth, a second wave of really important growth happens with sort of the synaptic sprouting and the creation of billions and billions of synapses. And those synapses that are essentially maintained through experience will stay in others and get reserved and it's very complex, very energy dependent process. And so for example, I can't remember the exact numbers, but something like 80% of the calories you eat when you're a newborn are consumed by your brain. And when you're our age, it's I think it's something like 24% of the calories you consume or use in your brain. And so the front loading of development and the speed with which all these things are happening means that these earliest experiences are foundational in creating the infrastructure for a healthy person. That's why I think early life experiences are so important and attachment is such an important thing to focus on. Everything important happens in context of that early relationships. And if those early relationships go well, it's sort of this inoculation. You actually just finished a big study and published it where if you take a group of kids that are having mental health problems and a lot of them are coming from the child welfare system and you look at their current functioning where they're 14. And here's what you find if you take kids that had low relational connection and high adversity, that means a high developmental risk all the way through their functioning is about, you know, in all these different brain measures, it's about 50% of what an age typical kid. And if you take a group of kids that are from that population, but they had, you know, they had some relational help and they had moderate adversity and then they go all the way through they had there about 75% of a normal no typical. That's just real quickly. So when you say the percentages, are you talking about like an FMR or scan or functional measurements. So when you look at function and cognitive social motor all these all these different brain media domains. So here's the really interesting thing is if you have a child who's in one of these low risk environments for two months and then the wheels fall off their family and then they end up in a high risk and bad environment for all the rest of this time. Their functioning is at 75% as opposed to 50%. Wow. So that window is so important. Two months. Two months. Two months. So months that mother had been cared for if there was some degree of safety predictability for her to provide that for her child. That is inoculating. Here's the worst one. And this one, of course, everybody who's a therapist knows because we do all kinds of work with kids that are not. If you have the first two months of life that are crap and then you get put into a decent place for the next 13 14 years. You function like the child who's in the high risk environment. That's heartbreaking. It is heartbreaking and it's not inevitable but it's heartbreaking apart because. The systems that these kids get into and the foster homes, the adoptive homes, the pediatricians, the therapists that they end up getting help from typically don't understand trauma. They're doing these kids through the lens of the DSM through this development lens. And so they'll be put on readily and they'll be put in social skills class when they're like a toddler. So none of these interventions are developmentally targeted so they don't work. So we spend a lot of money on those kids, but it's ineffective money. So the person that's listening right now that is feeling terribly guilty about their parenting or that knows that they had a really rough time or were adopted or, you know, can you speak to the hope or the change and, you know, what do we do about this now? Here's the key and it should be hopeful because the brain continues to be malleable. The challenges and again, this goes back to this concept of specificity that if you've got a system in your brain that appears to be dysfunctional, you can't change that system unless you activate that system. And so many of these systems that were impacted earlier in your life that may be continuing to play a disorganizing role and how you function are lower, they're lower in the brain. And they're going to be much easier to access through somato sensory routes. And so many, many people who are adults who may find themselves anxious and jumping out of their skin and all kinds of other symptoms that lead them into therapy. It may actually find that doing things like horseback riding and yoga and other things actually make them feel better. And so I'm not saying don't do therapy. I'm saying you need to figure out why do those things make you feel better, which is explainable. But you have to figure out to somehow to put together a plan with a therapist to understand the origins of this and to put together a plan to sort of take the sensitized distributed system and make it more, you know, typically regularly. And you need help to do that. I mean, it's. You can't go read a book in a closet. No. Then the other thing that this happens, particularly with adults is that when you have these problems, it leads to secondary tertiary cascades of problems. So if you failed in school, you know, and you've got all kinds of social problems and relational problems, just getting regulated isn't going to make that a lot better. It's good to be regulated, but you need to then do the work that goes with repairing yourself a steam around the fact that you blew up somebody relationships. And that you at some point in your life couldn't sit still in the classroom and got labels. And so that's one of the most powerful things of the more traditional therapeutic opportunities that you may have is that. The ordinary tertiary problems that sometimes are hardest to deal with once you sort of address the fundamentals of dysregulation. So translating it into kind of therapy language or the ways that we talk about attachment. What I love is like the more and more we learn it like no matter where you're coming at it from, we're landing in a similar spot. So language wise and what the audience will be familiar with is. Part of two is where the actual attachment system is zero to five or really two to five is, I mean, this is really rough, but as where you get your internal working model, which is your beliefs about the world, right, that relate to the underlying unconscious, fairly experiences. And that's what's very, very stable going forward. What we're talking about, for example, even just a little bit of stimulation can be overstimulating and that makes me think of we call it kind of on the blue side or the red side like blue being someone who's more avoidant dismissive. Their nervous system has learned to down regulate in order to stay stable. But those networks haven't been activated enough. So once somebody is in therapy and they're beginning to move closer to you, they don't move from a more avoidant stance to closeness. They move from an avoidant stance to dysregulation and because those muscles aren't practiced, that's my hometown kind of way of explaining why that you go from, you know, everything's fine, I'm zipped up, stay away just to preoccupation and to anxiety and to kind of this disorganized system. And does that feel like that fits kind of the way that you are thinking about this. And we have these different capabilities of dealing with stress, you know, one is the classic fight or flight. And the other one is this dissociative capability. And people tend to talk about these as if there's like you said, it's like a two-dimensional up and down sort of thing. The reality is you can activate both of those systems at the same time. Are you talking about polyvagal theory and well, polyvagal theory talks about this a little bit, but the way people have drawn this basically is they have. You know, hyperaroused and hyperaroused. And then when we're tolerant in the middle, yeah, that's definitely that's what's out there. Yeah, that's what's out there. And that's that's we don't use that because it's just sort of those overly simplistic translations that we think. Oh, fantastic complexity. It's actually a three-dimensional thing. And so, you know, we have a three-dimensional version of this. If somebody has the sensitized stress response and a sensitized hyperaroused response and a sensitized dissociative response, which is what you'd expect from an early attachment trauma. Because dissociation, fight or flight doesn't get you anywhere if you're a baby. It just gets you hurt. So you dissociate. So you've got these two systems that are sensitized. And so people usually zip themselves down with dissociation so that they'll be avoiding compliant, good little boy, good little girl. But once that starts to heal, all of a sudden you've got this hyperaroused response and then they get impulsive aggressive acting out and so forth. And so, you know, this is really sort of what we see with a lot of the kids that we work with. And they both of these adaptive systems are dysregulated and they can be dysregulated at the same time. It's a little bit like driving a car when you have a foot on the gas all the way down into foot on the brakes. You can drive by taking a little bit of foot off the brakes and you go. But if you take your foot off the brake completely, you'll go like 100 miles an hour. And that won't be a practiced skill. So you might take your foot off the brake all the way. And you can work and jerk around a little bit. So when you said three dimensional. The three dimensions are basically times one of the dimensions, which means that you can actually have over time. When somebody is experiencing a traumatic event, you can have the arousal systems activated and then you start to dissociate. And so you go down into the Z axis. And then for whatever reason, you're back in the moment and you get completely panicked and then you shut down because it's uncontrollable situation. And so every traumatic event has a fingerprint. The impact on your biology is going to be related to that fingerprint of experience. So some people get traumatized and the adaptive response they use again and again and again and again is dissociation. So they end up with this shut down. Some people will use mostly hyper arousal, but most people use both. Yeah, that's definitely we talk about it kind of on a continuum and that, you know, there's traits and states, but that everybody goes all around, you know, at any moment, any of us can be preoccupied or dismissive or disorganized. And that the goal is exactly what you're saying, learning to regulate and getting them back to the centered where we have our thoughts, we have our body, we have our feelings of our awareness of ourselves, you know, not dissociated. And when we sort of do that sort of the heuristic we have actually is overlayed on the bread. So we know that when you are, when you're calm, you have more access to your cortex and then more threatened you get them where your cortex shuts down. And so, same thing with dissociation, but it's a slightly different manifest. Well, I love that that's actually really helpful and I know that our listeners are going to be listening to this one over and over again jam packed with great stuff right on target with our people's interest. So thank you so much for your generosity. Would you like to share if people are interested in reaching out to you or anything that you would recommend that they turn to to read more. Probably the best way to get more information is to just Google my name and there's a lot of stuff that shows up. Dr. Bruce Perry. Yeah, and if you just remember that we have a website that's neuro sequential dot com. All right. Well, good because you know, a lot of times people get a little bit interested and then they'll read a little more and then we love introducing people that are into this to you. And you do trainings and everything is that right? We certify people and how to use this tool and use this approach and yeah, there's a certification process, but a lot of the stuff that we have is we distribute for free. The web-based metric is kind of complex. So I need some training. Well, great. Well, I can imagine lots of people hearing about this and really wanting to follow up on it. So thank you so much. And everybody, thank you for listening. If you enjoyed this, please give us a rating and review on your favorite podcast player. Also a quick reminder that we do have the course available. It's not me. That goes into some of this material as well. And patreon patreon dot com backslash therapist and censored. If you would like to support us, bring it by name just like this and bring more information to you. All right. We'll see you around the bin. [Music] Therapist Uncensored is Anne Kelly and Sue Marriott. This podcast is edited by Jack Anderson. [Music]