Why Laughing Matters to Soldiers with PTSD
The Act Resilient Training Method
By Genie Joseph, PhD
Overview:
The Act Resilient Training Method (ARTM) is based on 27 principles and employs over 100 interactive games to restore a sense of optimism and engagement with life. It uses expressive arts, improvisational comedy, laughter, theater games, emotional flexibility skills, Cognitive Behavioral Therapy, and a variety of self-soothing methods.
The momentum of group cohesion accelerates progress, thus ARTM is presented in a group format, with an ideal class size of 16-20 participants. Class meets either once or twice a week for one or two-hour sessions, for a period of eight weeks for the initial series.
Act Resilient has been presented to over 4,000 U.S. service members, veterans, military spouses, and military children. In self-reported surveys, participants indicate an over 80% reduction in stress and symptoms of trauma. ARTM has also been presented to wider, diverse populations, such as; incarcerated women, behavioral health practitioners in an Army hospital, doctors, nurses, at-risk youth, First Nations Youth, Polynesian youth, school principals, college students, and strippers. However, the battle rhythm of working with active duty soldiers often has meant some students had as little as twenty minutes of training, yet they still reported lowered stress levels and lifted “spirits” allowing them to return to work rejuvenated.
Why Laughter is Good Medicine, even for Trauma
Several hundred studies have reported numerous benefits of laughter, physically and mentally. Psychiatrist Victor Frankl, a holocaust survivor, says in Man’s Search for Meaning, “I never would have made it if I could not have laughed. Laughing lifted me momentarily…out of this horrible situation. Just enough to make it livable…survivable.”
While laughter cannot reverse a terrible situation, it can help the individual gain the upper hand long enough to make the best choices in unbearable circumstances. Humor is literally an important survival skill. Frankl continues: “Humor, more than anything else in the human makeup, affords an aloofness and an ability to rise above any situation, even if only for a few seconds.”
I had the opportunity to interview Vietnam POW US Navy Captain (Ret.) Gerald Coffee, who spent seven years in torturous conditions. In his book Beyond Survival, he said “Laughter sets the spirit free to move through even the most tragic circumstances. It helps us shake our heads clear, get our feet back under us, and restore our sense of balance and purpose. Humor is integral to our peace of mind and ability to go beyond survival.”
Paul McGee, PhD. says “Your sense of humor is one of the most powerful tools you have to make certain that your daily mood and emotional state support good health.” He cites more than 30 studies on how laughter improves the immune system. People with trauma often become immune-compromised, feeling weaker, resulting in more visits to the doctor and an increasing list of medications. Psychologist Steve Wilson, Director of the World Laughter Tour and trainer proposed that: “For many people who haven’t responded to traditional therapeutic interventions, laughter can be their doorway to re-engagement with their core self.”
After his first Act Resilient class, Benny, a Vietnam veteran in an in-patient PTSD treatment program at an Army hospital, said “That’s the first time I’ve laughed like that in 38 years.”
Generating laughter is a key component of Act Resilient for several reasons: it quickly brings people into present time, it interrupts the cycle of dwelling on the past, or focusing on physical pain, it is a tool for social healing and it brings people together through a shared, spontaneous experience. Through cherished moments together using multiple ARTM activities, we all laugh at some “silly” thing, and we feel ourselves included in a “communal,” connected healing experience, as we become aware that we’re helping one another alter the course of trauma in our lives.
Sharing a laugh breaks down social isolation. Dr. Fred Newman wrote extensively about the benefits of “social therapy” as a way to counteract the idea that healing occurs in isolation. In ARTM, we don’t view PTSD, or trauma, in the context of an individual psychological problem. Although there are individual elements of pain (the story), we view the psychological injury in a social context (e.g. deployment being a social experience) therefore, healing best occurs at the level of where the injury occurs -- within the support of the group. ARTM operates on the premise that healing, even of deep moral injuries to the soul, is best supported by the energy of fellow participants. Laughter unites us -- like a moment of “mind-melding,” as Benny called it, which makes us viscerally aware that we have more in common than we have differences. A deep belly laugh shared by a group creates a sense of belonging -- just long enough to crack the painful illusion of separation.
Laughter is most often done in the context of others. While people sometimes laugh alone, it is usually in the presence of others that we allow ourselves to laugh. Laughter is an important element in the toolbox of interpersonal and social communication. People who share a laugh often feel more connected. So, laughter for us is not just an end in itself, but a method of restoring well-being through positive interactions and relationships with others. As Martin Seligman, PhD says in his most recent book, Flourish, “The five elements (of well-being theory) are positive emotion, engagement, meaning, positive relationships, and accomplishment.”
While laughter is our secret weapon of healing in Act Resilient, it is just the start of the journey. Laughter is our psychological “open sesame” command that prepares participants to be receptive to releasing the grip of the past. I find that the majority of the thousands of soldiers and service members to whom I have presented ARTM, want to let go of the cycle of pain and torment. It’s just that they haven’t been presented with HOW to do it. Once you are shown HOW, it is easier to find your WHY to motivate you to continue to heal. For ARTM students we make a strong case for the best WHEN is right NOW. We call participants in an Act Resilient class “students” because we consider this an educational process. One reason is that we are re-training the brain.
Because Act Resilient is very present-motivated, there is no need to focus on the past, to re-live anything painful, or to regurgitate their -- Story of Pain. Many of the 27 operating principles of ARTM, and the over 100 interactive games, are designed to get participants into the present moment. It is in the present where pleasure can be experienced and healing can occur.
Focusing and dwelling on pain and suffering can leave a person “swimming in a trauma soup,” as one student described it. Often people who have been carrying an overwhelming burden of suffering for a long time have lost touch with what feels good, and for some, they may believe they don’t deserve anything good. So the first step is to restore the sense of being able to feel good. Feeling good generates the motivation to heal and creates a cycle of better self-care choices. It strengthens our willingness to continue living. Laughter is one way we build a rapid, positive momentum of good. For people who have lost faith in their ability to heal, providing rapid relief is integral to building their motivation to continue the journey.
As Groucho Marx quipped, “A clown is like an aspirin, only he works twice as fast.” This emphasis on “the need for speed” for relief from symptoms informs our method that rather than talking about “what happened” we teach students to focus on what good thing could happen next.
Our fundamental strategy is teaching students HOW to be oriented toward and focus on the present. For some students, this is a mental re-orientation -- as we break the habitual seductive lure of the familiar past. By helping students learn how to “get present” and focused, we can then offer the notion of “look forward.”
Much of what we do in Act Resilient is designed to help students re-direct their experience to be present-focused. We reinforce the idea that wherever your concentrated focus lies, you will have your greatest experiential opportunity. Laughter supports students to not get stuck in cognitive constructs such as good and bad, guilt, shame, etc but rather quickly gives them a visceral experience of joyful mirth.
Laughter stimulates hope which is a necessary prerequisite to generate enough energy to be willing to heal. Norman Cousins, journalist and Adjunct Professor of Medical Humanities for the School of Medicine at the University of California, Los Angeles, where he did research on the biochemistry of human emotions, believed that laughter and hope were pivotal tools for physical and mental healing. He wrote several books on how he used laughter to help him fight his heart disease. He said, “The capacity for hope is the most significant fact of life. It provides human beings with a sense of destination and the energy to get started.”
It takes energy to heal, and often those with severe PTSD -- especially those who are being heavily medicated to suppress these symptoms, do not even have the energy or the desire to heal. This is partly because it takes tremendous energy to repress painful, intrusive memories -- leaving very little energy or life force for the individual to engage in (and to be in) the present moment. This exhaustion is also because when the fight-flight, or freeze mechanism is triggered (which happens often to people with PTSD) dragging them with the force of a mental cyclone, there is a release of adrenaline and cortisol, which over time and through repeated triggers can leave the body depleted and drained - as well as addicted to this brain chemistry. Teaching students how to get themselves into the present and able to re-enter present awareness, is literally a matter of survival, as well as essential to the ability to maintain emotional equilibrium. Since it is in the present moment that one can enjoy life, or feel connected to anyone or anything good, our first task is to help students of Act Resilient to engage in the present moment.
No Time Like the Present
Getting people to become engaged with the present moment is very empowering. It is the antidote to feeling victimized by the past. The worst part of trauma is often not the initial event (s) but the cruel repetitive replays, through intrusive thoughts, memories, daymares, and nightmares. “I felt not only like I was living in an abyss, I was worried I was the black hole for my family,” one student shared. These sensations drag the person backward in time, with less and less energy to participate in their current life, their families, and even activities they once enjoyed.
For many soldiers suffering from PTSD, their sexuality is distorted or diminished, because healthy sexuality requires a flexible nervous system that can handle or even respond to their partner’s stimulation without being either numb or over-stimulated and thus shutting down in the blink of an eye. Act Resilient can be helpful to students experiencing disrupted sexual response, through re-setting the nervous system. Perhaps, according to Stephen Porges, author of The Polyvagal Theory, Neurological Foundations of Emotions, Attachment, Communication, and Self-Regulation, establishing healthy social engagement can mitigate the continuous cycling between shut-down and over-stimulation.
Changing Your Relationship to Time
Changing your relationship to time is one of the twenty-seven principles of ARTM. Students learn about how they personally relate to time (such as a primarily present orientation, a past orientation, or future orientation.) We also make a distinction between what we call Linear Time or Spherical Time. Once you learn your natural style, you also want to learn to develop the flexibility to adjust that time orientation.
For example, if you are a Spherical Time person, what is happening right now literally takes your full focus. If you are a Linear Time person, you are very much anchored to the clock -- and time runs you. In the military, the ability to master linear time is essential, but if all your time is spent with an external time orientation, you will burn out quicker. The goal is to master both methods of relating to time and to have the flexibility to be really present when you are at home with your kids, your spouse, and your pets. Without the ability to be in Spherical Time, your spiritual connection weakens.
People trapped in past trauma live as if their “time poles” or time orientation is reversed, or stuck. This is one reason why they feel an overwhelming magnetic pull backward, luring them away from the potential joy of the present moment. If there is a four-alarm fire going off in your brain, you can’t stop and smell the roses (and you probably didn’t even notice they were there). This is why in Act Resilient we talk about “healing your relationship to time” so that your natural polarity or pull of the present has more potency – literally making the present more attractive. Brain-Time-Reorientation is an important tool to help individuals feel naturally drawn to the present.
There are a number of excellent Mindfulness meditative methods which have been scientifically validated, such as has been brought to awareness by Jon Kabat-Zinn at the University of Massachusetts Medical Center who developed MBSR, Mindfulness-Based Stress Reduction. ARTM uses similar methods -- but we have modified them to adapt to student needs. For one thing, our methods do not require closing our eyes, staying still, or even feeling safe, to begin.
I am grateful to have learned from working with soldiers hospitalized with PTSD that the mere act of closing their eyes was either traumatic or literally impossible. The first time I embarked on a closed-eye visualization exercise -- which had always worked well in other group contexts -- I got a quick education. As soon as I said “Go to your safe place,” I was told with the directness that Army Corpsmen excel at: “I can’t close my eyes” and “I don’t want to see what I see when I close my eyes,” and “I never had a safe place.”
Building a Sense of Safety – Adding Vitamin “S”
This feedback was invaluable because it meant I needed to find mindfulness methods that didn’t require closing the eyes, or even staying still, or “going to your safe place.” The art of leading an ARTM class involves the finesse of creating and facilitating the experience of safety for students who do not feel safe. First, we have to learn how to create a sense of safety that is portable, renewable, and reliable. This is a matter of being able to re-direct the nervous system away from “F and toward S” – (away from fight/flight/freeze/fiddle – and toward calm, presence, ease, and safety).
For longer format classes, homework involves practice using the methods taught to create and strengthen a sense of safety at the level of breath, “altering cellular memory” and using tapping stimulation of acupuncture meridians. I call it mental “Vitamin S.” Being able to self-soothe using Act Resilient Vitamin S methods is an essential component of stabilizing progress. They help the student to feel self-empowered through being able to navigate and manage triggers that occur outside of class, and in the course of their daily lives.
I have a list of a dozen things a “trauma-informed” teacher can be aware of in order to help create and sustain a sense of safety in the room, but the most important one is the teacher’s own ability to “stabilize presence” and not resonate with the “trauma-vibe.” It has taken me a long time to develop what I would consider about 70% effectiveness to do this. And I only learned this 70% the hard way. As a behavioral health practitioner, if you are not taking very good care of your own energy, you will likely be negatively affected by those who feel like they are drowning. (Put your life-supporting mask on first! Keep your bubble strong, stay loose, shake it off, and give from fullness, not when your tank is empty.)
Early in my process of developing Act Resilient, I found myself volunteering at a VA hospital, learning as much from the men as they learned from me. If you have ever sat in a small treatment room with twelve large traumatized men, one of the things you notice is that there is a tremendous amount of tightly wound energy and movement happening: shaking legs, eyes scanning, random bursts of kinetic motion, heads turning at any sudden sound down the hall.
“My wife doesn’t even want me to go to church with her anymore. She says I shake the whole pew,” Rolando said. “Yeah, too bad you can’t harness the energy of PTSD,” Tony a brilliant medic in the group said, “We wouldn’t be so dependent on oil.” Tony was on to something. What if we could harness all that kinetic energy in some way? All this raw kinetic energy wouldn’t be a problem – it could provide a path to solution if we could “surf it” – ride the emotional waves, and celebrate the energy.
Therapy Animals to the Rescue
About two years into my process of creating The Act Resilient Method I brought a Therapy dog to class and he changed everything. I had rescued Oscar from the shelter, and he had a very rough past, having escaped from a situation where he was with several dogs who were forced to become wild pig hunters in Hawaii.
But Oscar, as I named him, was the sweetest, saddest, kindest dog and easily passed his Therapy Dog training and certification. Oscar had amazing instincts and the ability to read human emotions with laser-like precision. I would bring him into a circle of soldiers, hospitalized with PTS, and he would say hello to each one, but he would stop and sit in front of the person who was in the most distress. Even if they were stoically hiding their pain, Oscar knew who needed love and attention the most. He would sit in front of them, gaze into their eyes until they melted. With missing teeth and scars all over, Oscar had been a prisoner of abusers, and had escaped. And yet all he wanted to do was love and be loved. Even the toughest guys got down on the floor to cuddle and speak sweetly to this former prisoner of war as they called him. When I saw how Oscar could open hearts, and speak to people in a language beyond words, I was convinced that Therapy animals would be part of the Act Resilient program.
We worked with horses, dogs, pigs, llamas, and other therapy animals I became a Therapy Dog evaluator at Tripler Army Medical Center where I was on the board of The Human-Animal Bond program, a collaboration with the Red Cross. An entire Army Medical journal was devoted to reporting on the many benefits of Animal Assisted Therapy as well as combat support.
Movement is the Path to Wellness
What stuckness is to trauma, movement is to wellness. Many dance therapists, such as Dee Wagner, and others, believe that memory is not just in the mind, but in the body. And that the way to unwind and resolve even unconscious memories is through specific healing movements. In Act Resilient we use unique movement patterns to change the mind. Dr. Moishe Feldenkrais, the creator of The Feldenkrais Method, which has been very effective for people with chronic and intractable pain, is the author of Body and Mature Behavior: A Study of Anxiety, Sex, Gravitation, and Learning, believes that you can resolve past issues through moving the body in new ways in the present. “A fundamental change in the motor pattern will thereby leave thought and also feeling without anchorage in the pattern of their established routines. Habit has lost its chief support, that of the muscles, and has become more amenable to change.”
The mindless or rote movement has minimal therapeutic benefit. But Mindful movement, or what dance therapists call “authentic movement” has many benefits, because as Feldenkrais says, “Movement is life. Life is a process. Improve the process and you improve the quality of life itself.”
Dr. Feldenkrais believed that people could change their lives by changing how they move.
He believed that vivid use of the imagination was an essential ally in the process of healing and restoring movement. I am a huge fan of his method. I am also a fan of playful movement. Silly movement. We move in deliberately ridiculous ways such as you might see in a Laughter Yoga class. These movements break old patterns of behavior, generate laughter, and increase playfulness because of the healing benefits of moving in ways that are outside one’s familiarity.
I can only imagine what someone walking through the halls of the VA, looking in the small window in the treatment room might think to see twelve men jump in unison thundering “Re-Set” (explained below). Or see them tromping around like dinosaurs, or lumbering and growling like cavemen (to integrate the primitive brain). Or barking like junkyard dogs (to release pent-up aggression). Or dancing as if you had “Gumby (rubber) limbs,” or swaying to music like seaweed at the bottom of the ocean, or racing as a colony of ants, or even floating like butterflies. Yes, no healing process can be complete without the healing metaphor of transformation, so yes, you can imagine the sight as we invite six-foot-five Samoan and Tongan men to gracefully flap imaginary wings for the benefit of their audience of cohorts. Laughter fills the atmosphere with hope and delight. One student called it “purposeful-silliness.”
Dr. Richard Ries, Resiliency Subject Matter Expert formerly at Tripler Army Medical Center, greatly admired Act Resilient and dubbed it, “Re-Silly-Ence.”
At first glance, our class might look like “Kindergarten for soldiers.” However, inviting people to access the return to their playful selves can be very healing. Reconnecting with child-like playfulness seems to help wash away the burden of suffering, as Victor Frankl observed. This is an example of using the pre-traumatized creative brain to help the injured brain to reconnect itself. I ask people in the class if they have seen old-fashioned record players, and then I give the example of trauma being like a needle stuck in a record’s final grooves. It keeps cycling through the same experiences. Any new event or interaction is not seen in a new light, but is stuck in a groove, filtered through “trigger-eyes.” You have to pick up the needle and move it to a new position. What we do in class is “Re-Set” the grooves.
Re-Set and Starting Over
“Re-Set” is one activity we do in class to reduce the stigma of mistakes. Whenever someone makes a mistake -- and many of the games we do are designed to cause everyone -- (including myself) to make mistakes, so that we can do a “Re-Set.” We use the “re-Set” as a physical metaphor for rebooting the mind and starting over with fresh experiences. It is a very silly move -- where you bend your knees, gyrating or corkscrewing down, then pop up like a Jack in the Box, jumping and waving your arms in the air, yelling “Re-Set.” It is done as a group and in a festive manner. In this way, the group gets to celebrate an individual’s mistakes, in a sense seeing mistakes as an opportunity to celebrate.
The message here is that you are not alone in your mistakes. As a group, we enthusiastically celebrate an individual’s mistakes with the same gusto as his or her successes -- because we are all in this together. Almost all Act Resilient activities will cause people to “fail” at some point, and part of healing is to build tolerance and acceptance of failures because they are part of what life offers. “Re-Set” takes less than three seconds, but it packs a punch in mental benefits. We encourage students to do this at home, at work, or when they’re alone.
If you physically do this action enough times, according to Dr. Richard Bandler author of Using Your Brain -- for a Change and the co-creator of Neuro-Linguistic Programming, you create a positive anchor or memory -- and then just thinking the word “Re-Set” to yourself and seeing the compelling mental image of your group leaping and yelling these words, creates a mental re-set. It takes the fear out of making mistakes, illustrating to students that they can use the power of the present to re-set their focus, (not just by cognitive devices) but by moving their body in new ways, no matter how much guilt or suffering has been experienced.
Why We Play
Some people view play as a frivolous activity -- the enemy of work. In his book “Play, How it Shapes our brain, Opens the Imagination, and Invigorates the Soul,” (2009) Stuart Brown, M.D., the founder of the National Institute of Play, explains how critical play is. “The ability to play is critical not only to being happy but also to sustaining social relationships…I sometimes compare play to oxygen -- it’s all around us, yet goes unnoticed or unappreciated until it's missing." In military families, where one or more are suffering from PTSD, there is a cascade effect; the whole family is affected, often suffering secondary trauma, including the children and even the family dog. Whenever possible, the Act Resilient leader works with the entire family, even the dog, and play is a very valuable asset in restoring healthy interactions.
I have observed many situations in which a soldier will deny how much his mental and moral injury is affecting his family. Military families are often very resilient. They have learned to cope with varying degrees of effectiveness, but the family pets often resonate with and pick up disturbed energy, and will start expressing it through misbehaviors. I ask, “How’s Rover doing?” This is often a doorway for conversation because many people will gladly talk about their dog, whereas they may not be so open to sharing how they are feeling.
In a therapy situation, according to the US Army Medical Department Journal, on canine studies, with a therapy dog present, soldiers will talk twice as much as if a dog was not present. I am very interested in the well-being of the dog and have several methods to quickly help a dog de-stress, which I learned from over a thousand hours of volunteering at the Hawaiian Humane Society, where dogs arrive in all kinds of emotional states.
One method we use, developed by Dr. Roger Callahan, is called Thought Field Therapy (TFT). TFT offers a basic pattern for reducing symptoms of trauma, that is learned in a few minutes. It is a tapping technique utilizing acupuncture points and can be used with babies, animals, and people of all ages. Teaching the soldier this simple self-soothing technique helps the dog -- and the soldier at the same time. Often they are motivated to heal their own suffering when they understand their emotional states are negatively affecting the dog.
One Navy Seal, Rick, who entered the Act Resilient class, was so reactive, so intense, that even sitting in a chair he seemed wired into a high-voltage circuit. Because of his hair-trigger response, his children felt they had to “walk on eggshells.” Even his beloved dog, Rollo, a shepherd mix, didn’t want to be in the same room with him, even if it was the dog’s dinner time. After eight weeks of class, Rick reported that his children were no longer afraid of him (after we taught his kids a simple method to quickly calm him, which made them feel they had more control). The whole family used the TFT method on themselves, and the dog, to help reduce their reactivity. And when Rollo, his dog, started sleeping with him again, it helped Rick sleep much better. With his dog snoring at his back, Rick’s spirits lifted, and it gave him a strong confirmation that healing was possible for him and his family.
Mirroring Movement
Many Act Resilient activities also involve mirroring of movement, which means copying the movements of someone else as if you were a perfect mirror. Young children learn by observing and imitating, and when they try new movements -- this ignites new neuronal connections. You can make new neuronal connections at any age. The ARTM Third Level of Resilience makes use of this idea by integrating moving in ways that are playful, making faces, using funny voices, and doing anything outside the box of routine. This begins to “turn-on” the “Learning Switch” in the brain, to use Anat Baniel’s term. I just discovered her book, “Move into Life” (2009), where she states:
“Science has now shown that neurogenesis, that is, the production of new brain cells, not only occurs naturally but can also be enhanced at any age. The adult brain retains impressive powers of neuroplasticity -- the ability to change its structure and function in response to experience… In recent research by neuroscientist Alvaro Pascual-Leone, at Harvard Medical School, it was shown that in learning new skills, both thinking and moving our bodies in new ways, could alter the function as well as the structure of our grey matter… It is clear to me that as our brains form new patterns we experience a renewed energy, discovery, excitement, enjoyment, and sense of being alive."
Moving in new ways is good for everyone, but it is very useful for traumatized brains, which I believe become less fluid and less coherent, as more resources are dedicated to the fight, flight, freeze, and numbness (and I add another behavioral element to the “F” list,“fiddle” for the nervous random or repetitive fidgety movements.) However, new movement that is deliberate and involves awareness can help the brain to become relaxed, engaged, and spontaneous. We believe that Mirrored-Movement requires the whole brain to work together, creating a more coherent, healthier mind.
With this activity of Mirrored-movement, we cultivate the third type of resilience, which is where healing naturally occurs. (In ARTM we talk about three types of resilience, and it is the third type that is most useful because it is learnable, and it is possible to strengthen). In this third type of resilience, (which is capable of being restored, even in the presence of tremendous trauma), Mirrored-Movement is a key strategy. Healthy children are naturally resilient -- partly because of this continuous movement, ferocious learning, imitation, and their willingness to try new things -- to laugh, to play, to invent, and to use their whole brains.
In Mirrored-Movement, we are replicating this healthy brain state by imitating each other’s movements, which means we will use our bodies in new ways. Using our bodies in deliberately playful ways generates laughter. Multiple studies speak to the restorative nature of neuro-plasticity by creating new or stronger neuronal connections. Norman Doidge, M.D., author of The Brain’s Way of Healing, says “Neuroplasticity is the property of the brain that enables it to change its own structure and functioning in response to activity (my italics) and mental experience….This very sophistication, which involves brain cells being able to constantly communicate electronically with one another, and to form and re-form new connections, moment by moment, is the source of a unique kind of healing.”
These Mirrored-Movement exercises are often circle games. (The circle itself has healing potential, as is seen in many indigenous peoples, such as Polynesians, Native Americans, etc. who gather in circles to make everyone feel equal, included, and connected.)
Most Act Resilient games can be adaptively played for those in wheelchairs. For those capable of standing, we stand in a circle facing each other. One game we play, that has almost infinite variations, is a staple of improvisational comedy and theater games, called ‘the Name Game”. I would start by saying my name in a goofy way, with a silly motion, or a funny face, or melodic voice -- saying “Geeeeeenieeeee”. The group would then say my name back to me, copying everything like a living mirror. For the first day, I calibrate my zaniness to what I think they can handle, but with each round or new meeting, I deliberately up the ante on absurdity.
We take turns around the circle. The person next to me would say his name in a way that expresses his mood, his energy, his playful spirit -- and the group echoes the motion and sound back to him, and so on. This simple game has shown multiple therapeutic benefits, such as it:
· Gets people out of their comfort zone or withdrawn shell
· Generates laughter
· Inspires creativity, spontaneity, and personal expression
· Gets people to move in new ways
(critical, as trauma makes people move in habitual ways)
· Creates group cohesion
· Empowers people and makes them bolder
· Doesn’t generate resistance -- (Because it’s fun)
Act Resilient for Active Duty
Approximately 75% of my work with Act Resilient has been with active duty in garrison, yet some of our activities can be used in other very challenging personal situations. Many of these methods take little time and can be used recreationally, such as even during brief breaks and R & R in a combat zone when service members have a few moments of downtime. I had one soldier who was very shy, yet excelled at one of our improvisational games called “Badada” which is a fast-paced right-brain word game that also has the added dimension of clapping, use of rhythm, and the ability to respond at a pace faster than rational thought. It did wonders for her self-esteem as she was the champion of this game and literally unbeatable. When she deployed, she taught her buddies this game, and it was a great tension reliever, as well as a quick brain tune-up that was ‘like three red bulls without the calories or chemicals” as she put it. Teaching this game to others got her the nickname “Badada Queen” and she earned the respect of her combat buddies who really had her back.
The “Name Game” is used as a warm-up to get students into the mood and swing of laughter, especially if they may have come from stressful events right before class. I use it to create a familiar anchor, and I almost always vary it in some way to keep it fresh. Examples might be “Say your name as a five-year-old” or “As a young girl wearing high-heels for the first time,” or “As the Fox in Little Red Riding Hood.” I allow them to make creative suggestions for how we will play the game.
There is another reason why I usually start a group with the “Name Game.” As simple as this game is, it is highly indicative of states of mind. It allows me to take the psychological temperature of each one quickly without having to resort to asking “How are you?” This might result in a military-trained answer such as “Outstanding!” While introverts may initially play the game differently from extroverts, once students step across the threshold of the Act Resilient world, the differences between temperaments become negligible.
What’s in a Name?
Since I have worked with over 4,000 service members, I have noticed that people who are feeling suicidal play the game differently. While I wouldn’t use this as a method of diagnosis, (since I am not a psychologist), it does function, as I have come to see, as a very reliable “warning system” identifying those who may be having suicidal thoughts or feelings. People who are suicidal will show different unconscious indicators. When it’s their turn, I’ve observed that their nervous systems appear to short-circuit, a split-second freeze, perhaps followed by random eye movement, changes in skin color, and other indicators of unconscious stress (as might be observed in someone lying). I deliberately run this game at a fast pace to bypass conscious editing, keeping people in their spontaneous brains, and allowing these aberrations to become more apparent to me.
For people who are in serious internal turmoil and immediate crisis, there is often a delay in their response that stands out once the rhythm and momentum of the game are set. It appears that people who are having suicidal feelings "pretend" to play, but there is no spirit in the way they say their names. It is almost as if they can only tentatively put their name out there -- because they don’t plan to “stay” here. In the Hawaiian tradition, your name carries and expresses your spirit, your mana. Hawaiian babies are not given their name until their one-year baby luau, to make sure the spirit plans to stay. Although the differences are subtle, those who are having suicidal thoughts may say their name, but there is no “mana” or spirit coming through in their presentation.
The Three Faces of Resilience
In recent years, the military has put a great effort into trying to identify, develop and support resilience. In spite of excellent intentions, I feel there are “mission critical” flaws in some of the current practices of addressing resilience. For one, the concept that resilience is viewed as a “thing”, which you either have -- or don’t have, is too fatalistic a view. If it is perceived as a “thing”, like luggage, you can lose it in the presence of too much adversity, while being in harm’s way, or experiencing major trauma. A viewpoint suggesting resilience is an internal human quality absent in some of the human race promotes selective biases.
In contrast, in Act Resilient, we talk about the three faces of resilience. They are all related and support each other, but have different functions and represent different layers of experience. Most importantly, the third layer can be strengthened before, during, or after adversity, so it makes sense to concentrate on this type of resilience as it is more fluid.
To explain this concept, the first kind of resilience I call Natural Resilience, which can be seen as psychological hardiness. Some people just seem tougher, able to handle more adversity and bounce back quicker and stronger. You can even see this in a hospital nursery when some babies just startle more easily and take longer to regain calm. Perhaps there are variations in in-utero experience that may account for these differences. It certainly speaks to the importance of enriching the experience of the unborn child and protecting the baby from unnecessary stress and adversity.
The second type of resilience I call Acquired Resilience is when individuals are faced with adversity and become stronger for having faced the challenges. This second model of resilience is like the methodology of boot camp in which young cadets face almost more than they think they can take. Some will quit (or be eliminated, as is the intention of this weeding-out approach) and the rest will become battle ready, stronger, and more confident of their abilities to serve in their military environment. We have all seen people who have grown up in terribly adverse circumstances become strong, compassionate, and ethical individuals. However, there are others, in the same neighborhoods, even the same families who suffer greatly from their circumstances.
The third type of resilience I call Restored Resilience. It is the most important because it can be learned at any time, regardless of the level of pain, injury, or trauma endured. It is never too late -- or too early -- to increase Restored Resilience. I have used elements of the ARTM methods with military babies as young as 18 months (where they learn self-soothing methods to calm themselves) to 85-year-old Korean War Veterans.
Act Resilient is useful as a preventive method, as well as an intervention method, once trauma has occurred. One of the principles of restoring the third type, Restored Resilience, is to make good use of the parts of the brain that are intact and healthy -- to help heal the parts of the brain that are injured. This is an important lens to view PTS not as purely a psychological disorder (e.g. “You’re crazy!”) but as an injury. Former Army General Peter Chiarelli has done much to champion this view of PTS as an injury, hoping to educate people and remove the stigma for those who have this diagnosis.
Connecting to the healthy parts of brain function ignites creativity, imagination, wonder, awe, joy, playfulness, spontaneity, imitation, intuition, and humor. This leads to immediate feelings of pleasure, vitality, hopefulness, optimism, engagement, empathy, cooperation, and connection. In short, connecting with these sides of oneself helps to restore resilience and renew interest in living. This is why play, laughter, and the other methods of Act Resilient are important prevention and intervention tools.
Play Your Self Well
As mentioned previously, laughter is a way of cracking open a door to personal freedom from the confines of excess stress. Our next primary strategy in the Act Resilient toolbox is Improvisational Comedy. If you have seen the TV show “Whose Line is it Anyway?” we play games like those, although we have modified the games we play for maximum therapeutic benefits. We are not performing skits to try to be funny, we are role-playing to help heal identity crises (I view trauma as partially an identity crisis). We are using movement to create character such as what was done in the 14th Century with the predecessor of improvisational comedy, Commedia De l‘Arte. We are “making fun,” generating laughter, turning social conventions upside down, and playing with infinite possibilities.
In one role-reversal game (which is wonderful for family sessions) called “Who’s the Boss?” the children get to be the parents and boss their actual parents around -- and the parents get to whine and complain and be helpless -- so everyone gets to see the absurdity of their frozen roles. This also works well with military groups where they get to have a field day playing with rank and role reversal. In one battalion-level class of about 90 participants, we played this game; when it was his turn, a private made an officer “Lick the floor!” and the good-natured leader actually did it. The entire room cheered, and many people laughed so hard that they fell to the floor themselves. I only had the opportunity to work with this soon-to-redeploy group once, but they told me it had done wonders to restore their esprit de corps.
It Takes Energy to Heal
As a leader of ARTM, you are continually utilizing World Laughter Tour Director, Steve Wilson’s description of silently “taking the temperature of the class” through being very observant of the levels of energy, readiness for something new, or rising stress levels. Sometimes a group has too much energy and needs to expend it and blow off some steam. This doesn’t mean getting rid of it, it means using it as a resource. Sometimes they don’t have enough energy, and we use games that cause the energy levels to rise, so it’s important that an Act Resilient leader knows how to manage these moods and orchestrate energy shifts as needed.
For example, we might do one activity that is very stimulating, that requires total brain coherence and focus. It challenges participants to be fully engaged in the moment. These games sometimes involve brain challenges such as; rhythm, word association, clapping, remembering, complex patterns, and -- to support spontaneity -- not even a fraction of hesitation when it is your turn to do the exercise. These mind games burn calories, even though they don’t look like traditional exercise exertion methods. When working with active duty, I request permission from the leader in charge, for the group to remove their uniform jackets, and work in their T-shirts, because we do work up a sweat. “I feel like steam is coming out of my head,” Jorge, a Marine, said after one of these mentally and physically challenging exercises.
Sometimes you have to “blow off” a lot of energy before the nervous system can socially engage or focus on more mindful activities. After a very energizing game, in the next exercise, we might bring the energy level down -- sitting in a circle, doing a mindfulness game, and reconnecting through social engagement. We might focus on one body part, such as the lower jaw, which we drop, and feel “Who this person is who has a completely slack jaw?” We drop the voice, maybe even slump or lumber as we move. Without judgment, we move into this character. How does he or she sound? This game is called “Duh, huh!” With your lower jaw completely dropped you say “duh, huh!” And laugh in a goofy way, like someone from the movie Deliverance -- (hey, comedy works with archetypes, but we make sure to insult everyone equally). Then speaking in the slack-jawed, low-pitched sound, you let your voice and facial gestures bring out the character. Playing characters who are very unlike you is therapeutic -- and relaxing the jaw is a great way to release tight, controlled, angry energy and emotions (even without having to directly express your personal story).
Freeing Up the Mouth
Freeing up the mouth, jaw, and neck are essential prerequisites to be able to experience a sense of safety, I believe. Many people with TBI or PTS will have discomfort, pain, or misalignment in the neck which may be subclinical or unaddressed by traditional diagnostic methods. With a minimal discussion about stress points in the body, we do dance therapy movements that bring new freedom to these areas.
Once we get the class a little more embodied (meaning they are actually back in their bodies – which is essential as people with chronic pain or trauma often live as if they were functioning a short distance from their bodies) -- we can begin to add words. I have worked with inmates, First Nations Youth, and others, with such trauma that the entire primary focus has to be “getting back into the body” before they can be receptive to the more verbal portions of Act Resilient.
For groups ready to engage verbally, we might begin with another staple from improvisation and theater games called The Chain Story. In this circle game, I start the story with an animated delivery (using a lot of body language and often funny voices) and a provocative beginning (that is appropriate and relevant to the age and culture of the group) such as “I woke up this morning and there was this little green man on my pillow and he was jumping up and down saying…” And then the next person adds a few words or a sentence “You better get up because they are giving away free TV’s at Walmart…” and then the next person adds something to advance the story, or spin it in wacky new directions, but always keeping a central storyline until it comes back to me and I create a resolution and ending.
By adding funny voices, accents, or “rolling vowels” (which melodically and comically extend the vowel sounds), we can bring another dimension to these stories, which usually generates barrels of laughter. We encourage students not to do these games in their normal speaking voice or persona, but instead to use their body, face, voice, and imagination to create characters; this is an excellent way to loosen the shackles of their persona. For example, a super-tough guy might be asked to play a super-wimp, or float like a butterfly. It is one of the ironies of the Act Resilient method that through playing other characters who are very unlike you, it seems to cause a kind of integration. By living, breathing, experiencing diversity, (who you are not), and then dropping it like a jacket, your true identity has the space to blossom.
Improv is an old art form at least as far back as the 14th Century, with Commedia Dell’arte, with its humorous stock stereotype characters such as the miserly merchant, the foolish lusty old man, the devious servant, the military officers filled with false bravura. To these, we add more modern archetypes such as John Wayne, Marilyn Monroe, The Terminator, Boris and Bullwinkle, Julia Childs, or whoever else the class wishes to invoke.
Alternating Stimulation and Relaxation
Upon completion of a calm exercise, we might switch back to another high-energy exercise. I believe this rapid alternation of stimulation and relaxation helps the brain to do its own re-setting. This is important to restore flexibility to brains that are somewhat rigid due to hyper-vigilance, or disengagement. The more flexible the brain’s neuronal connections, the less likely it is to get stuck in old habits and thoughts, and the more resilient it becomes. In the course of a single class session, we will repeat the alternations of high-intensity play, followed by brief periods of restful play. You see this repeated cyclic pattern when you watch puppies play. Play activates the brain, body, and nervous system. Rest allows the body to settle into balance and integrate what has been learned.
The brain has a receiving mode -- and then it has an integration mode. (This is why it is tragic to expect children or adults to sit still for 45 minutes or longer of lecture-style teaching.) There is a natural desire for play and for rest, and we want to assist people to find their own body rhythm and play cycle, which may have been disrupted or deregulated through trauma. Giving people time to play does not make them lazy or unable to work, rather it recharges their battery.
In fact, numerous studies by Stuart Brown, M.D., and others demonstrate that the switch from “outside control” (work) to “inside-directed” activity is very valuable. Playfulness allows you to feel a greater sense of freedom, more in control of your time, your nervous system and body, and ultimately your destiny.
People stuck in an intense state of trauma have very little, if any, energy left to play. They may feel as if they have lost their desire, interest, or even their willingness to have fun. Starting to play may not seem logical to them, or they might not know how to begin. It takes a lot of energy to run a traumatized brain because there is an excess of triggering stimulation. This creates an imbalanced state energetically and emotionally.
Sometimes in class, we have to drain excess energy. More often than not we have to raise the energy or “life force” of the group. The idea of a life force is essential to harness the power of self-healing. Many cultures recognize the importance of claiming and raising your life force in order to be in your power and to heal. To name a few ancient practices, Chinese acupuncturists call it Chi, Japanese martial artists call it Ki, East Indians call this spiritual energy Prana, and Hawaiians refer to your spiritual energy as your Mana. By whatever name you call it, it is one of your strongest allies on the healing journey. In the early days of identifying combat operational stress and trauma, such as in WW11, it was called Shell Shock, but I think a more accurate name would be Soul Shock.
Soul Shock
I have a theory that PTSD is like whiplash to the Soul, where the various aspects of self get shocked out of alignment. This is why people don’t feel like themselves, or that they can’t get control over their emotions, their mind, or their memories. It is also why traditional methods of talk therapy and medication may not be sufficiently effective, because they don’t address this fundamental imbalance. To address “Soul Shock” you need to address the moral and spiritual wounds. And you also need to teach the person how to get the various aspects of themselves to function as a unified whole. Working with your Chi or your life force is one way to support this healing -- and the first step is often to raise it because when people’s Chi gets too low, they aren’t interested in getting well or even going on.
Because healing takes a lot of energy, the first step is to generate more. Just as in sports training, we use energy to generate more. The team huddles up and powers up! Depending upon the needs of a specific group, we will use more or less of the high-energy games. We also use the power of the group to generate more energy than an individual could do on their own. We use the group energy to set a high bar, non-verbally inviting those with low energy to engage more fully. (If someone’s physical injuries prevent them from moving vigorously, we always invite them to be safe, take care of their body -- and instead do the motions in their imagination. If they allow the energy of the group to enliven them, it will, just as fans in the stadium are charged by the players, and the players are also responding to the roar and enthusiasm of the crowd.)
In games that involve timing or rhythm, the lower-energy people naturally rise to the momentum of the group without my having to discuss this dynamic or ask anyone to change. This is one example of how we create group cohesion, to allow the “field of energy and enthusiasm” to lift the individuals.
Filling Your Resilience Tank
Using a gas tank as a metaphor, I draw a picture of a tank on the board. Dr. John Gray (Men are from Mars, Women are from Venus) talks about “Love Tanks,” which can either be full or empty. I talk about “Resilience Tanks” which can feel high or low, and can fluctuate all day long. We talk about what fills your tank -- giving you strong feelings of resilience, and what lowers your tank -- making you feel tired, vulnerable, irritable, reactive, and stressed.
Additionally, we talk about how self-care impacts resilience, such as how much sleep you are getting and what that does to your resilience levels. When you have had a good night’s sleep, you can handle the daily stressors more easily. Without sleep, with a poor diet, or without healthy exercise, your resilience tank levels drop. Stressful interpersonal interactions may lower your tank. Arguing with coworkers, or your boss criticizing you, can cause your resilience tank to veer towards empty. We ask students individually to write their own “resilience recipes” so that they understand both their personal stressors and triggers – as well as what to do when these disturbing events occur so they can be best prepared, and thus quickly regain equilibrium.
Chronic pain, for example, is a huge energy drain on your resilience tank. We offer one or more of our self-soothing methods to calm the pain responses in people who are actively suffering physical pain. Ironically, people who have endured a large amount of pain may be feeling disconnected from their bodies, in order to get through the day. When the body is “screaming in pain” for an extended period of time, we may be forced to ignore it; consequently, the body stops communicating, even good feelings, and we lose touch with the inner wisdom of what the body needs to heal.
Restoring this “inner-guidance system” is critical to supporting students to make better choices across all areas of their lives. We call it restoring “Personal True North” where your “inner compass” comes back online and you can filter decisions through your internal sense of right/wrong, good/bad, up/down, etc.
Micro Movements Toward Well-Being
“Micro Movements” is another game we use to increase presence and healthy connection to the body. “Micro Movements” are very tiny. They begin in the imagination. Then you set the intention to move -- before you take the first step. Linking up your sense of intention with the actual movement creates a mindfulness experience instantly, even without hours of meditation. Then staying connected to your intention to move as you move, crates brain coherence. You have to move very slowly until you can maintain this connection. Then you begin to experience the “high state of flow” where time disappears, everything becomes this moment, this little movement. Students need to be reminded to “go even slower, make your movements even smaller. Now twice as slow, twice as small.” A hand or foot may just move a half-inch per second. It slows the brain down, which causes “fast thoughts” to fade away.
Micro-Movements can be fast or slow. Once students master slow, we introduce fast.
Usually, there is a gentle quality because the intention and focus are not about disconnected movement, but on listening, feeling, and engaging with good feelings. We use the breath to help people connect a tiny movement with the inhale or exhale, thus creating “authentic motion” which is very integrative. Other micro movements might be circular, spiral or “S” curves around the focus of pain. We want to bring movement back to stuck places, to accelerate healing. These exercises are inspired by the work of Dr. Moishe Feldenkrais, which restores healthy body function by slowing down, reducing effort, and redirecting the origin of everyday movements.
One game designed to bring awareness and play to micro-movements involves imagining you are in an old, red, English telephone booth. If I have “Dr. Who” fans in class, they get it immediately. You imagine you are in this tiny area, and you have to move as fast as you can, but you are only the size of an ant. So you have to take minuscule steps, very quickly, so that it would take you about fifteen seconds to cross the width of the booth. I call out “faster, faster” and the results are fun to watch as students have to express both speed and “eintsy-teensy” movements simultaneously.
This is both a physical and mental exercise that creates a deliberate, confined, and energized movement. Plus it’s very fun! We can do this game as a race in teams, and use the rest of the group to cheer people on, all while I am side-coaching the student to take “smaller, tinier, faster steps” and so on. These “moving mindfulness” exercises benefit the mind and the body and encourage people to really feel and deeply listen to their body again. As Nohm Gamady, an energy healer in New York City, says, “Hear your body – heal your life.”
Laughter, Movement & Shaking Strategy
We do raise the energy of the group in order to generate enough positive energy to “move people off their positions,” or views about themselves. Laughter, movement, and shaking are three key strategies. Shaking is another movement method we use. I ask participants to play one of their favorite upbeat songs on their phone, or I haul out my early rock and roll music, like Twist and Shout or Great Balls of Fire. Standing in place, you just shake! Shake everything! Your whole body should vibrate. This is a circle game, and sometimes we combine it with mirroring -- where one person goes to the center of the circle and we imitate their crazy moves. Everyone shakes at a different level of intensity. Faster or harder is not necessarily better, but this really gets the circulation moving.
An example of the healing practice of shaking can be seen in an Ashram in Bali, where a teacher named Ratu Bagus who teaches Bio Energy Meditation, will have students shake for 45 minutes or longer. With numerous benefits to physical and mental well-being, this practice has spread to at least eighteen other countries. I believe even a three-minute shake recharges “the internal resilience battery” and makes people much more willing to engage. Shaking is an Army-approved de-stress method used in the Care Provider Support Program, which we taught at Tripler Army Medical Center, which we presented in many resilience briefings. NASA uses a sophisticated expensive machine to induce intense shaking to increase circulation and help astronauts reorient to the Earth’s gravity field. Our preference is to use the low-tech, do-it-yourself version of shaking to a favorite song because you can pay attention and really listen to what speed your body wants, which is part of the therapeutic value of shaking.
Organized Chaos
No two Act Resilient classes are the same, as the needs of the individuals dictate which activities, or in what order, will be most beneficial. Previously, I mentioned that sometimes we have to expel and harness excess energy. This would be followed by a cooling down activity to get the maximum benefit from switching states. Fairly rapid alternating between two extremes of energy creates balance.
This is one reason why interacting with or even just watching puppies, kittens, and other animals play is therapeutic -- these curious young animals practice this alternation between bursts of energy, followed by calm moments. Watching them play triggers our mirror neurons allowing us to get a similar “contact balance.”
So in spite of the “improvisational structure” of the classes, there is a method at work, and the class follows a general pattern of warm-ups, energizers, focus games, mind games, improvisation, and character work, followed by mindfulness or stress-busting skill.
In the longer classes (eight weeks or more is the recommended length), there is homework, journaling, and checking in on everyone’s progress with their emotions and social skills -- based on what they are learning in class. Breaks and social time are very important for integration, so we build them into the schedule. Most classes will plan a couple of social get-togethers outside of class, independent of my guidance.
While there is a loose structure that lends a sense of safety, we are modeling the idea of living an “improvisational life,” as you can’t prepare for or control all of the factors of your life. Rather you need to build the “flexibility muscle” which increases your third level of resilience, making you more adaptable to change. I interviewed Vietnam veteran, Lt. Colonel Jim Channon (US Army Ret.) about whether or not he thought improvisation was a useful skill for soldiers. He said “After all my excellent training as a leader, the first day with boots on the ground in Vietnam there were fourteen incidents I had to respond to. Only two of them I had been trained for.” Channon was well known for his non-traditional strategies, which include the use of improvisation, imagination, collaboration, and intuition. He has an excellent record to support his methods. As he explained to me, “Not one of my guys died in combat under my leadership.”
As students enter an Act Resilient class and at the end of each class, participants are asked to rate their current stress level on a zero-to-ten scale, with ten being their highest level of stress, and zero being no stress at all. It is common for people, especially active duty, to enter class with an 8 or 10 – stress level rate. By the end of class, most people will either be at zero stress levels or will have at least dropped by 50%. The overall average drop in self-reported stress levels is over 80%.
Most participants say Act Resilient was their favorite class, and the most useful intervention to help them manage their stress levels. In their class journals, they state that they are getting along better with family and coworkers. Additional post-class feedback indicated that they are managing their emotions more effectively, and handling changes and transitions that are occurring in their lives. They also report feeling more confident in social situations and are no longer at a loss for words. Self-reporting data has shown participants’ minds are working better and they feel more engaged with life. As Bailey, one participant put it, “Act Resilient helped me feel like myself again.” Many times students have confessed on the last day of class that when they started, they were suicidal. “But I don’t feel that way anymore. I am kinda looking forward to what’s next,” another student said. Toby said, “Act Resilient is good for the soul.”
The Act Resilient Method book is available on Amazon
For more information: www.Act-Resilient.org GenieJoseph9@gmail.com
Sources Cited:
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3. McGee, Paul. haharemedy@del.net
McGhee, Paul E. Health, Healing, and the Amuse System: Humor as Survival Training. 3rd Ed. 1999. Dubuque, IA: Kendall Hunt Pub.
The Laughter Remedy was created by Paul E. McGhee, Ph.D.. Paul was a pioneer in humor research, laying the groundwork for the current interest in the health benefits of humor. After receiving his Ph.D. in developmental psychology in 1968, he spent 22 years conducting basic research on humor and laughter while teaching at the university level. He is internationally known for his own humor research, and has published over 50 scientific articles and 13 books on humor.
4. Wilson, Steve. World Laughter Tour, Inc., Columbus, Ohio. info@worldlaughtertour.com.
5. Newman, Fred & Goldberg, Phyllis. Performance of a Lifetime: A Practical-Philosophical Guide to the Joyous Life. 1996. Castillo International (? NY where Castillo Theatre is).
Newman, Fred. Let’s Develop: A Guide to Continuous Personal Growth. 1994. Castillo International.
6. Seligman, Martin E. P. Flourish: A Visionary New Understanding of Happiness and Well-Being. 2011. NY: Simon & Schuster.
7. Cousins, Norman. Anatomy of an Illness: As Perceived by thePatient. (20th Anniv Ed, orig 1979). 2005. NY: W.W. Norton.
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