PDF Summary:What Happened to You?, by Bruce Perry and Oprah Winfrey

In What Happened to You?, Oprah Winfrey and renowned psychiatrist Bruce D. Perry discuss how childhood trauma can have a severe and lasting impact on the brain—and thus our worldview, health, and behavior—sometimes without us even realizing it. They discuss why the developing brain is so susceptible to trauma, why trauma survivors often experience flashbacks, and why it’s so important to address your trauma to live a healthy and happy life. They also describe how to begin the healing process with compassion for yourself and others.

Throughout our guide, we’ll connect Perry and Winfrey’s ideas to those in other popular books on trauma, such as Bessel van der Kolk’s The Body Keeps the Score. We’ll also elaborate on the authors’ main themes, such as trauma’s impact and the healing process. Finally, we’ll provide information and resources to help those struggling with trauma find high-quality care.

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Perry and Winfrey suggest that this can create a vicious cycle. When the child doesn’t have a loving home, she struggles to connect with others and develop loving relationships. Without these relationships, she doesn’t experience love in other places and continues to drift further from others. She therefore becomes more isolated and never experiences the love needed to break the cycle.

Attachment Theory: The Importance of Loving Caregivers

Perry and Winfrey’s assertion that the caregiver-child relationship impacts brain development aligns with the basic tenets of attachment theory. Attachment theory suggests that to develop healthy social, emotional, and cognitive skills, an infant must receive consistent love and care from at least one caregiver.

Attachment theory started with a basic observation, first noted by psychologist John Bowlby in the 1950s. Bowlby noticed that when babies can’t see their caregivers, they have a common set of behaviors, including crying, screaming, and searching. He called these attachment behaviors. According to Bowlby, the evolutionary purpose of attachment behaviors was to make sure that an infant’s attachment figure, or caregiver, paid attention to the infant. Bowlby theorized that babies who exhibited these behaviors received more care and were therefore more likely to survive.

Over the next two decades, psychologist Mary Ainsworth challenged and extended Bowlby’s theory. Like Perry and Winfrey, Ainsworth suggested that if a caregiver consistently responds to an infant’s attachment behaviors with love, the infant’s brain develops in a normal, healthy way. On the other hand, infants who experience abuse or neglect struggle to develop more advanced brain functions such as cognition and social skills.

Using this basic idea, Ainsworth suggested that infants can have one of two attachment styles. Infants who receive consistent, loving care (and as a result experience normal brain development) are securely attached. Infants who receive inconsistent or abusive care (and as a result have impeded brain development) are insecurely attached. She further divided insecurely attached babies into two categories:

• Anxiously attached babies experience high anxiety when separated from their parents. When reunited with their caregivers, they’re difficult to soothe.

• Avoidantly attached babies don’t experience stress when separated from their caregivers. Furthermore, when they’re reunited, they often ignore the caregivers.

Like Perry and Winfrey, Ainsworth believed that your attachment style has long-term effects on cognition and social skills, including your ability to develop healthy relationships. However, it wasn’t until the 1980s that researchers began to explore the connection between infant attachment and adult relationships. In Attached, Amir Levine and Rachel Heller explain this research, suggesting that there are three adult attachment styles:

• Secure attachers are confident in their partner’s affection for them and are caring, nurturing, and compassionate.

• Anxious attachers worry that their partner will leave them and seek constant reassurance.

• Avoidant attachers distance themselves from their partners.

Researchers once thought that your attachment style as an infant directly led to your attachment style as an adult. Today, however, scientists such as Levine and Heller suggest that infant attachment style is just one of several factors that influence adult attachment. Other factors include your temperament, your parents’ stress levels, and whether you spent time with caregivers other than your parents.

2) An Overactive Stress Response

Childhood trauma can also overactivate a child’s stress response, making them hypervigilant and anxious. Perry and Winfrey explain that children who live in an abusive home must always be alert for signs of abuse. This means that their stress responses are very sensitive—more often than not, they’re in a fight-or-flight or dissociative state.

While this overly active stress response helps a child survive at home, in other settings, it isn't so helpful. Perry and Winfrey suggest that a heightened stress response can make it hard for the child to focus in school, make friends, and trust adults. Children who experience trauma are often misdiagnosed with ADHD because they have trouble sitting still and concentrating.

Like the inability to love, a heightened stress response can create a vicious cycle. Perry and Winfrey suggest that if teachers, coaches, and other students aren’t aware of the child’s traumatic experiences, they’ll view the child’s behavior as disruptive. They’ll probably get frustrated, which will further isolate the child, making them less likely to reach out for help and less motivated to follow the rules.

How to Recognize and Respond to Trauma: Advice for Teachers, Coaches, and Mentors

As the authors suggest, if adult mentors don’t notice that a child has an overactive stress response and is experiencing trauma, the child can become even more isolated. So how can adults recognize the signs of stress and trauma and respond in a supportive way? Keep these three things in mind:

1) Recognize: The first step is to know the common indicators of childhood trauma. In addition to the anxiety and concentration problems mentioned by Perry and Winfrey, these indicators include forgetfulness, constant complaints of feeling sick, aggression, extreme perfectionism, and general depression or lack of effort.

2) Respond: If you do suspect that a child is experiencing trauma, questioning her about it may not be the best strategy. This could make the child feel like she is under pressure or in trouble, which could cause her to recede further. Instead, be aware of the ways that trauma might contribute to her behavior, and respond to this behavior patiently and compassionately.

3) Report: If you believe a child is suffering from trauma, you should report it. In the US, educators such as teachers and school counselors are mandatory reporters, which means that they must report child abuse. But anyone in the US can report abuse by calling the Childhelp National Child Abuse Hotline at +1 (800) 4ACHILD, or +1 (800) 422-4453.

The Long-Term Effects of Childhood Trauma

For children who suffer abuse, trauma’s impact on the developing brain tends to create long-term issues. Perry and Winfrey mention three broad ways that childhood trauma can impact people in the long-term: 1) mental and physical health issues, 2) flashbacks and triggers, and 3) unrecognized behavioral patterns.

Let’s take a look at each of these.

1) Mental and Physical Health Issues

According to Perry and Winfrey, suffering a traumatic event in childhood increases the risk of a range of mental and physical health issues later in life. People who experienced trauma as children often experience depression and anxiety, as well as physical symptoms such as chronic pain and increased risk of heart disease.

(Shortform note: Research confirms Perry and Winfrey’s assertion that trauma often causes long-lasting mental and physical health issues. Studies suggest that between 40% and 50% of trauma survivors experience anxiety and depression after a traumatic injury, and that these symptoms can last up to 20 years after the injury. In one study, 68% of trauma survivors reported experiencing physical health problems five years after the traumatic event.)

Perry and Winfrey note that doctors sometimes dismiss the physical manifestations of trauma. These doctors might tell patients that the pain is imagined or “psychological,” implying that it isn't actually happening in the body. However, the authors maintain that the mind and body are connected. Physical pain from trauma is real, and addressing that pain is an important part of any care plan.

(Shortform note: The authors’ emphasis on the mind-body connection is part of a broader movement in Western medicine: In the past several decades, Western doctors and scientists have found direct links between mental health and physical health. However, this movement isn't new—studying the mind and body together was a common practice in Western medicine until the 17th century. Furthermore, non-Western medical practices, such as Chinese medicine, have always been highly aware of the mind-body connection.)

2) Flashbacks and Triggers

Another common long-term effect of trauma is flashbacks, in which a trauma survivor relives a traumatic moment. Perry and Winfrey explain that flashbacks occur when the brain creates long-lasting associations between the circumstances surrounding a traumatic event and the stress response. For example, if a drunk father hits his child, the child’s brain may create an association between the smell of alcohol and a state of fear. The brain learns that when that smell is present, bad things happen.

Our brains create these associations to protect us from similar situations in the future. For example, the next time the child smells alcohol, his brain will recognize the situation and tell him to hide or run away. However, the brain can sometimes do its job too well, triggering our stress response even if we aren’t in danger.

For example, when the child grows up, he might suddenly experience a stress response when a middle-aged man smelling of alcohol approaches him. Even if he isn’t in any immediate danger, he might feel suddenly anxious and uneasy. As we discussed above, this type of sustained stress response can have negative impacts on our mental and physical health.

The Positive Side of Mental Associations

While Perry and Winfrey talk about mental associations in a negative sense due to their role in perpetuating trauma, other authors claim that we can use these associations to create positive change in our lives. Here are two examples of how to use mental associations to your advantage:

1) Evidence suggests that you can use associations to help improve memory, by linking emotions and images to the thing you want to remember. For example, if you want to remember someone’s name, you could connect it to the lyrics from one of your favorite songs. By connecting their name to the positive emotion that you associate with the song, you’ll be able to recall it more easily.

2) Evidence also suggests that associations can help increase productivity by creating positive associations between your workspace and your efficiency. For example, working on your bed will make you less productive because you associate your bed with relaxation and sleep. Meanwhile, working at a desk you solely designate for work will make you more productive, as you’re in a space clearly linked to productivity.

3) Unrecognized Behavioral Patterns

In addition to creating health problems and triggering flashbacks, trauma can influence behavior in more subtle ways. According to Perry and Winfrey, trauma survivors often develop negative habits and ways of seeing the world, sometimes without realizing it.

As we’ve mentioned, experiencing love and care as an infant allows us to develop healthy relationships later in life. Childhood trauma can create a vicious cycle in which the child doesn't know how to receive love and becomes more and more isolated.

Perry and Winfrey explain that these behavioral patterns continue to influence us as adults, even though we might not be aware of them. When someone experiences trauma, they come to expect the same patterns of abuse that they suffered as children. This can inhibit our ability to form healthy relationships, especially if we’re unaware of how our childhood trauma is influencing us.

For example, if a person is abandoned by her parents when she’s young, she might later struggle to develop trust in intimate relationships. Because of her childhood trauma, she might mistakenly come to expect that anyone who says they love her will leave. However, if she isn’t aware of her childhood trauma or the effect that it has on her, she might think her feelings are based in reality. This could make it difficult for her to form a trusting relationship.

How to Change Behavioral Patterns

Behavioral patterns can be hard to break, especially ones formed in childhood and rooted in trauma like those the authors describe. However, behavioral psychologists have identified several strategies for changing behavior:

1) Self-reflect: Before changing a behavior, you must first figure out what it is that you want to change and how it’s impacting your well-being. You can do this individually through mindfulness practices or by talking with someone you trust.

2) Keep motivation in mind: We’re more likely to achieve our goals when we have the motivation to do so. Before beginning the process of changing behavior, write down your motivating reasons for changing. These could be related to how your behavior impacts you or your loved ones.

3) Start small: When thinking about your goals, start by identifying small situations where you can change your behavior or thoughts. For example, if you want to practice self-love, commit to writing down one nice thing about yourself every day.

4) View setbacks as learning opportunities: Patterns are hard to change for a reason. If you have a setback and lapse into old behaviors, don’t give up or get angry with yourself. Instead, think about what you can learn from the experience and how you might react differently in the future.

It’s important to note that these strategies won't work for everyone. As we’ll shortly explore, trauma-related behavioral patterns often require more processing than regular patterns. However, this advice could be helpful for those who’ve already made progress in working through trauma.

Part 3: The Healing Process

In the previous section, we discussed how trauma can have short-term and long-term impacts on our worldview, behavior, and relationships. Fortunately, there are ways of addressing and working through trauma to help us heal and develop healthy relationships.

Perry and Winfrey maintain that every person going through trauma has a different background and different needs. There is no one-size-fits-all solution to trauma.

(Shortform note: While doctors agree that there is no one-size-fits-all care plan for trauma, there are common guidelines that care providers can follow. For example, the National Child Traumatic Stress Network uses the Psychological First Aid model, which outlines several “core actions” that doctors should perform. These include speaking to the patient with compassion and understanding, stabilizing symptoms, connecting the patient to support networks, and offering practical assistance to the patient and their family. While the details of each case will be different, these “core actions” help doctors make sure that they’re providing positive care.)

Still, the authors mention several important pieces of advice for anyone struggling with trauma: Lean on your community, ease your stress response in small doses, and have compassion for yourself and others. Let’s explore each strategy in detail.

1) Lean on Your Community

According to Perry and Winfrey, the most important factor in dealing with trauma is experiencing love and support from your community. They note that even for people without trauma, having meaningful social connections is an excellent indicator of mental health.

However, when healing from trauma, the authors maintain that these social connections become even more important. To process traumatic events, survivors need to share their thoughts and feelings with a supportive community. Trauma often makes its victims feel unloved and unworthy. But healthy, communicative relationships can help people feel listened to, cared for, and validated.

(Shortform note: While healthy, meaningful connections improve our mental health and can help trauma survivors heal, unhealthy relationships can make people feel unsafe and unloved. So, how can you tell whether your relationships are healthy? Mutual respect, trust, honesty, and compassion are just a few key elements of a healthy relationship. When developing a connection with someone, think about whether you feel safe with them and can be yourself.)

Perry and Winfrey suggest that ideally, a therapist can be a part of this community. But they also note that not everyone has access to a therapist, and Perry maintains that a supportive community of family and friends can be just as valuable.

Cost-Effective Trauma Care Resources

As Perry and Winfrey note, not everyone has the resources to get help from a therapist. Moreover, while family and friends can sometimes support trauma recovery, in other cases, they can actively hinder it. In The Body Keeps the Score, van der Kolk maintains that many people don’t know how to respond when someone shares their trauma. Nonprofessionals might not want to listen, or they might react in a way that causes further harm, such as not believing the survivor’s story.

Fortunately, there are many free or low-cost ways to get help with trauma. Here are some services dedicated to providing high-quality and affordable care:

• In the US, the Rape, Abuse, and Incest National Network (RAINN) is an organization devoted to helping victims of sexual violence. They operate the national sexual violence hotline, which can be reached at +1 (800) 656-HOPE. Their website also has a live chat feature and information on sexual assault prevention and awareness.

• Organizations such as Open Counseling can help you find affordable therapy near you. On Open Counseling’s website, you can find therapists by state, verify that they’re licensed, and see if you qualify for state-funded therapy.

• Adult Survivors of Child Abuse is an international organization that helps adults who suffered childhood trauma find therapy and get the care and support networks that they need.

2) Ease Your Stress Response in Small Doses

As we mentioned earlier, trauma creates associations in the brain that can retrigger the stress response even years after the event. When this happens, it becomes difficult or impossible to think rationally. According to Perry and Winfrey, this makes it hard to work through trauma.

(Shortform note: In The Body Keeps the Score, van der Kolk elaborates on the authors’ point that flashbacks make it hard to work through trauma by noting that flashbacks often shut down specific areas of the brain: in particular, those related to speech and language. This can make it impossible for the trauma survivor to speak about her experience. To combat this, van der Kolk suggests several strategies that can help the victim express and process their trauma, including free-association writing and developing bodily awareness through meditation.)

Therefore, according to the authors, the first step in working through trauma is to ease your stress response. This retrains the brain’s neural pathways to recognize that it isn't actually in danger, allowing you to think rationally and process traumatic memories. Perry and Winfrey offer two concrete tips for beginning this process:

1) Use rhythm: Rhythmic activities such as walking, dancing, and coloring can help regulate the body and brain when processing traumatic memories. According to Perry and Winfrey, rhythmic motions have a therapeutic effect on us, a connection that goes back to the womb, when we hear our mother’s heartbeat and associate it with safety.

(Shortform note: While Perry and Winfrey claim that rhythm is therapeutic because it connects us to our time in the womb, another theory suggests that rhythm is beneficial because it can change our brainwaves. Scientists have found that listening to rhythmic music causes our brainwaves to resonate with the rhythm. This increases blood flow and activity in the brain, which can improve concentration and reduce anxiety.)

2) Address trauma little by little: Perry suggests that on a biological level, we can’t think or talk about a traumatic memory for more than a few seconds before our brain tries to protect us and our stress response kicks in. Because of this, Perry and Winfrey recommend addressing trauma in small doses. Thinking about a traumatic memory for only a few seconds (as opposed to forcing yourself to think about it for longer) will make it easier to regulate your stress response.

The need to process trauma bit by bit also helps explain why having a large, healthy, and robust community is so important. According to the authors, having a long conversation with one person won't be as helpful as having many shorter conversations with different people.

The Body Keeps the Score: Advice on How to Ease the Stress Response

The authors’ advice on easing the stress response complements van der Kolk’s advice in The Body Keeps the Score. Like Perry and Winfrey, van der Kolk recommends using rhythm in the healing process. He extends the authors’ point by recommending pairing rhythmic activities with deep breathing (for example, while practicing yoga) to help with regulation and centering.

Furthermore, while van der Kolk doesn't explicitly mention healing in small doses, he does maintain that trauma treatments shouldn't seek to overwhelm the patient. This is why he argues against Cognitive Behavioral Therapy (CBT). CBT addresses trauma by exposing trauma survivors to triggers for extended periods of time, in an attempt to desensitize the patient. Van der Kolk believes that this overtaxes the body’s stress response and could make the patient more susceptible to flashbacks.

Lastly, van der Kolk agrees with Perry and Winfrey on the importance of engaging with a broad community of people. He notes that trauma can make survivors feel alone and out of sync with others, and having a strong community can help reestablish a sense of connectedness. In particular, he recommends pairing community with physical movement. Group activities such as exercise classes can make trauma survivors feel physically in sync with others, providing a sense of connection.

3) Have Compassion for Yourself and Others

According to Perry and Winfrey, another important element of healing from trauma is having compassion. When a person experiences trauma, they can often feel like something is wrong with them. They might feel that it’s their fault that they can’t sustain a healthy relationship or that seemingly random triggers create anxiety or dissociation. However, Perry and Winfrey emphasize that having trauma doesn't mean that something is wrong with you.

This is where the title of the book comes from. Instead of asking ourselves and others “What’s wrong with you?”, Perry and Winfrey say, we should ask, “What happened to you?” This question, which they borrow from the work of psychiatrist Sandra Bloom, shifts the focus from blaming the trauma survivor to understanding their past. It introduces compassion into the healing process and helps the survivor understand that it isn’t their fault.

Sandra Bloom and “What Happened to You?”

Sandra Bloom is an internationally renowned psychiatrist and author. In her work, she advocates for communication and compassion in trauma care, particularly in institutions such as schools and hospitals. Bloom’s philosophy of asking “What happened to you?” grew out of this work. She explains that well into the 20th century, doctors sent trauma survivors to large institutions that didn't treat the underlying causes of trauma or offer personalized care. Instead, these institutions saw trauma survivors as dangerous and focused on keeping them away from the rest of society.

Bloom began her work to change the stigma around trauma in the 1970s, inspired by the work of Quaker trauma care centers. These centers, which began in the 19th century, emphasized “moral treatment,” and they created a peaceful community in which trauma survivors could heal. Bloom drew on this theory to develop her own care plans and shift the focus to “What happened to you?” instead of “What’s wrong with you?”

While people like Bloom are working to reform trauma care, the stigma that trauma survivors are dangerous and should be removed from society continues today. For example, stereotypes depict trauma survivors as “crazy” or as a danger to themselves and to others. These stereotypes and stigmas can make trauma survivors feel like there is something wrong with them, leading to the shame and guilt that Perry and Winfrey mention.

The Body Keeps the Score: Other Treatments for Trauma

While van der Kolk agrees with Perry and Winfrey on the importance of community, regulation, and compassion in treating trauma, he also refers to several other treatments that Perry and Winfrey don’t mention. These include:

Internal Family Systems Therapy (IFS): This method of therapy is based on the idea that everyone has different “parts,” or aspects, of their personality—one part of you is more closed-off and private, while another is more childlike and joyful. Together, these parts form an internal “family,” each with different needs.

The theory of IFS is that trauma disrupts the balance of these different parts, causing some to do more work and others to be locked away. For example, a traumatic event may cause you to be more closed-off to protect yourself from reliving traumatic memories. The closed-off part of your personality therefore takes over, while the childlike, joyful side is hard to access. IFS uses mindfulness and talk therapy to reconcile the different parts of the “family.” This allows the trauma survivor to access all the different parts of her personality, leading to a healthy, whole self.

Using touch as a way of healing: Touch therapy includes massage, hugs, and rocking. This method helps patients become more aware of the sensations in their bodies, including pressure points and tension. It then releases these tensions, helping patients become more comfortable and relieving physical symptoms of trauma.