Extracts from van der Kolk's 'The Body Keeps The Score'

Content warning: Mental health, PTSD, trauma, abuse

From time to time I read a book so important to my developing sense of Self I want to buy it for all the people I love. You might remember a few years ago I bought secondhand copies of Harriet Lerner's 'The Dance of Intimacy' and mailed it to the first 15 people who expressed interest (fwiw I now recommed 'The Dance of Connection' even more). Like Uri, I've given away several copies of MJB's 'Rewriting the Rules'. And now I wish I could get everyone I know to read Bessel van der Kolk's 'The Body Keeps The Score'. I read this book seeking to understand the role of intergenerational trauma in my own family, as well as the impact of more direct trauma on many people that I love.

It's a long book and not an easy read. Here is a selection of short quotes that particularly resonated with me. Comments in [square brackets] are mine.

The Body Keeps The Score - Mind, Brain and Body in the Transformation of Trauma

Bessel van der Kolk

Facing trauma

One in five (US) Americans was sexually molested as a child; one in four was beaten by a parent to the point of a mark being left on their body; one in three couples engages in physical violence. A quarter of us grew up with alcoholic relatives and one out of eight witnesses their mother being beaten or hit.

As human beings we belong to an extremely resilient species... but traumatic experiences do leave traces, whether on a large scale (on our histories and cultures) or close to home, on our families, with dark secrets being imperceptibly passed down through generations. They also leave traces on our minds and emotions, on our capacity for joy and intimacy, and on our biology and immune systems.

While we all want to move beyond trauma, the part of our brain that is devoted to ensuring our survival (deep below the rational brain) is not very good at denial... it may be reactivated at the slightest hint of danger... These posttraumatic reactions feel overwhelming... survivors often fear they are damaged to the core and beyond redemption.

Trauma compromises the brain area that communicates the physical, embodied feeling of being alive... We can now develop methods and experiences that utilise the brain's own natural neuroplasticity to help survivors feel fully alive in the present. There are fundamentally three avenues: 1) top down, by talking, connecting with others, and allowing ourselves to know and understand what is going on with us; 2) by taking medicines that shut down inappropriate alarm reactions, and 3) bottom up: by allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage or collapse that result from trauma. Which of these is best for a particular survivor is an empirical question. Most people require a combination.

We have studied the efficacy of many different forms of treatment, from medications to talking, yoga, EMDR, theatre and neurofeedback.

Understanding mind and brain

Scared animals return home, regardless of whether home is safe or frightening... is it possible to help (traumatised people) become attached to places and activities that are safe and pleasurable?

Patients often complain about a vague sense of emptiness and boredom when they are not angry, under duress, or involved in some dangerous activity... some people are only attracted to people who hurt them. Fear and aversion, in some perverse way, can be transformed into pleasure. Endorphins - morphine-like chemicals that the brain secretes in response to stress - (may) play a role.

Medications... suppress their problems without addressing the underlying issues.

Neuroscience

In the early 90s some people had begun to divide the world into left-brainers (rational, logical people) and right-brainers (the intuitive, artistic ones)... We now know that the two halves of the brain do speak different languages. The right is intuitive, emotional, visual, spatial and tactual, and the left is linguistic, sequential and analytical. While the left brain does all the talking, the right carries the music of experience. It communicates through facial expressions and body language and by making the sounds of love and sorrow: by singing, swearing, crying, dancing or mimicking. The right brain is the first to develop in the womb, and it carries the nonverbal communication between mothers and infants. We know the left hemisphere has come online when children start to understand language and learn how to speak. This enables them to name things, compare them, understand their interrelations, and begin to communicate their own unique, subjective experience to others.

[HD: I have a poorly developed theory that while my left-brain development was massively supported, my right-brain somehow got overlooked.]

The left brain remembers facts and the vocabulary of events... The right brain stories memories of sound, touch, smell, and the emotions they evoke.

Under ordinary circumstances the two sides of the brain work together more or less smoothly... however, having one side or other shut down is disabling.

The insidious effects of constantly elevated stress hormones include memory and attention problems, irritability and sleep disorders. They also contribute to many long-term health issues, depending on which body system is most vulnerable in a particular individual... Even though the mind may learn to ignore messages from the emotional brain, the alarm signals don't stop. The emotional brain keeps working, and stress hormones keep sending signals to the muscles to tense for action or immobilise in collapse. The physical effects on the organs go on unabated until they demand notice when they are expressed as illness. Medications, drugs and alcohol can also temporarily dull or obliterate unbearable sensations and feelings. But the body continues to keep the score.

The anatomy of survival

The most primitive part (of the brain), the part that is already online when we are born, is the ancient animal brain, often called the reptilian brain (responsible for all the things newborns can do)... Breathing, eating, sleeping, pooing and peeing are so fundamental that their significance is easily neglected when we're considering the complexities of mind and behaviour. Yet... it is amazing how many psychological problems involve difficulties with sleep, appetite, touch, digestion and arousal. Any effective treatment for trauma has to address thee basic housekeeping functions of the body.

The limbic system ('the mammalian brain') ... takes off after a baby is born. It is the seat of emotions, the monitor of danger, the judge of what is pleasurable or scary. It is also a central command post for coping with the challenges of living within our complex social networks. The limbic system is shaped in response to experience, in partnership with the infant's own genetic makeup and inborn temperament... The brain is formed in a 'use-dependent manner' (aka neuroplasticity). If you feel safe and loved, your brain becomes specialised in exploration, play and cooperation; if you are frightened and unwanted, it specialises in managing feelings of fear and abandonment.

Together the reptilian brain and limbic system make up the 'emotional brain'. In the second year of life the frontal lobes, which make up the bulk of our neocortex (the top layer of our brain), begin to develop at a rapid pace. (Around the age of seven)... a life organised around frontal-lobe capacities: sitting still; keeping sphincters in check; being able to use words rather than acting out; understanding abstract and symbolic ideas; planning for tomorrow; and being in tune with teachers and classmates. [HD: So what are the implications if we were positively rewarded for these kinds of things from around the age of one?]

Crucial for understanding trauma, the frontal lobes are also the seat of empathy - the ability to 'feel into' someone else. Trauma almost invariably involves not being seen, not being mirrored, and not being taken into account. Treatment needs to reactivate the capacity to safely mirror, and be mirrored, by others, but also to resist being hijacked by others' negative emotions.

If the amygdala (the brain's smoke detector) senses a threat... it sends an instant message down to the hypothalamus and the brain stem, recruiting the stress-hormone system and the autonomic nervous system to orchestrate a whole-body response... Once the danger is past, the body returns to its normal state fairly quickly. But when recovery is blocked , the body is triggered to defend itself, which makes people feel agitated and aroused.

Functioning effectively in a complex work environment or a household filled with rambunctious kids requires the ability to quickly assess how people are feeling and continuously adjusting your behaviour accordingly.

Ordinarily the executive capacities of the medial prefrontal cortex (MPFC) enable people to observe what is going on.. and make a conscious choice. Being able to hover calmly and objectively over our thoughts, feelings and emotions (an ability I'll call mindfulness throughout this book) and then take our time to respond allows the executive brain to inhibit, organise and modulate the hardwired automatic reactions preprogrammed into the emotional brain. This capacity [which both my parents lack, and don't realise they lack] is crucial for preserving our relationships with our fellow human beings.

In PTSD the critical balance between the amygdala (smoke detector) and the MPFC (watchtower) shifts radically, which makes it much harder to control emotions and impulses.

Victims of childhood sexual abuse may anaesthetise their sexuality and then feel intensely ashamed if they become excited by sensations or images that recall their molestation, even when those sensations are the natural pleasures associated with particular body parts... (They) are rarely in touch with the origins of their alienation. The challenge is not so much learning to accept the terrible things that have happened, but learning how to gain mastery over one's internal sensations and emotions.

Depersonalisation... is one symptom of the massive dissociation created by trauma. I regularly see depersonalised patients who tell me horrendous stories without any feeling. All the energy drains out of the room, and I have to make a valiant effort to keep paying attention.

Numbing is the other side of the coin in PTSD... many untreated survivors start out with explosive flashbacks, then numb out later in life... This is a particular problem with traumatised children. The acting-out kids tend to get attention; the blanked-out ones don't bother anybody and are left to lose their future bit by bit.

Body-brain connections

For humans... as long as the mind is defending itself against invisible assaults, our closest bonds are threatened, along with our ability to imagine, plan, play, learn, and pay attention to other people's needs.

Our culture teaches us to focus on personal uniqueness, but at a deeper level we barely exist as individual organisms. Our brains are built to help us function as members of a tribe. Most of our energy is devoted to connecting with others... Almost all mental suffering involves either trouble in creating workable and satisfying relationships or difficulties in regulating arousal (becoming enraged, shut down, overexcited or disorganised). Usually it's a combination of both. Being able to feel safe with other people is probably the single most important aspect of mental health. Numerous studies of disaster response around the globe have shown that social support is the most powerful protection against being overwhelmed by stress and trauma.

Social support is not the same as merely the presence of others. The critical issue is reciprocity: being truly heard and seen by the people around us. For our physiology to calm down, heal and grow we need a visceral feeling of safety. No doctor can write a prescription for friendship and love.

In the past two decades it has become widely recognised that when adults or children are too skittish or shut down to derive comfort from human beings, relationships with other mammals can help. Dogs and horses are now extensively used to treat some groups of trauma patients.

New approaches to treatment

The polyvagal theory helped us understand why (techniques like yoga, breath exercises, body work, martial arts, singing and drumming) worked so well. All rely on interpersonal rhythms, visceral awareness, and vocal and facial communication... The body keep the score: If the memory of trauma is encoded in the viscera, in heart-breaking and gut-wrenching emotions, in autoimmune disorders and muscular/skeletal problems, and if mind/brain/visceral communication is the royal road to emotion regulation, this demands a radical shift in our therapeutic assumptions.

Losing your body, losing your self

Many traumatised people lose their sense of purpose and direction... their relationship with their own inner reality is impaired. How could they know what the sensations in their bodies, the basis of all emotions, were trying to tell them? The implications are clear: to feel present you have to know where you are and be aware of what is going on with you.

[HD: I'd like to read Damasio's 'The Feeling of What Happens']

Damasio argues that the core of our self-awareness rests on the physical sensations that convey the inner states of the body. [HD: I don't believe any member of my immediate family has this kind of self-awareness.]

Agency: Owning your life

'Agency' is the technical term for the feeling of being in charge of your life: knowing where you stand, knowing that you will have a say in what happens to you, knowing that you have some ability to shape your circumstances. [HD: I feel like I grew up with a sense of agency, but without the sense of self-awareness of inner states, as described above. In other words I knew I could shape my circumstances, but I didn't know what I really needed.]

Agency starts with what scientists call interoception, our awareness of our subtle sensory, body-based feelings: the greater that awareness, the greater our potential to control our lives. Knowing what we feel is the first step to knowing why we feel that way. If we are aware of the constant changes in our inner and outer environment, we can mobilise to manage them. But we can't do this unless our watchtower, the MPFC, learns to observe what is going on inside us. This is why mindfulness practice, which strengthens the MPFC, is a cornerstone of recovery from trauma.

The price for ignoring or distorting the body's messages is being unable to detect what is truly dangerous or harmful for you and, just as bad, what is safe or nourishing. Self-regulation depends on having a friendly relationship with your body. Without it you have to rely on external regulation - from medication, drugs like alcohol, constant reassurance, or compulsive compliance with the wishes of others.

Somatic symptoms for which no clear physical basis can be found are ubiquitous in traumatised children and adults.

Alexithymia... Many traumatised people simply cannot describe what they are feeling because they cannot identify what their physical sensations mean. Not being able to discern what is going on inside their bodies causes them to be out of touch with their needs, whether it involves eating the right amount at the right time, or getting the sleep they need.

Children

'The roots of resilience... are to be found in the sense of being understood by and existing in the mind and heart of a loving, attuned and self-possessed other.' Diana Fosha

Men without mothers

[re Bowlby, Winnicott et al...] These men who studied the role of mothers in children's lives had themselves been sent off to school at a vulnerable age, some time between six and ten, long before they should have faced the world alone. Bowlby himself told.. that just such boarding school experiences probably inspired Orwell's 1984, which brilliantly expresses how human beings may be induced to sacrifice everything they hold dear and true - including their self of self - for the sake of being loved and approved of by someone in a position of authority.

Attunement

Secure attachment develops when caregiving includes emotional attunement... A secure attachment combined with the cultivation of competency builds an internal locus of control, the key factor in healthy coping throughout life.

Winnicott thought that the majority of mothers did just fine in their attunement to their infants. But... if a mother cannot meet her baby's impulses and needs, 'the baby learns to become the mother's idea of what the baby is'. Having to discount its inner sensations, and trying to adjust to its caregiver's needs, means the child perceives that 'something is wrong' with the way it is. Children who lack physical attunement are vulnerable to shutting down the direct feedback from their bodies, the seat of pleasure, purpose and direction.

Children have a biological instinct to attach... Whether parents are loving and caring or distant, insensitive, rejecting or abusive, children will develop a coping style based on their attempt to get at least some of their needs met.

Avoidant attachment - 'dealing but not feeling' vs. anxious attachment - 'feeling but not dealing'. [HD: Eagle-eye vs. mouse-eye?]

Attachment researchers think that the three 'organized' attachment strategies (secure, avoidant and anxious) work because they elicit the best care a particular caregiver is capable of providing.

... avoidant toddlers are likely to become adults who are out of touch with their feelings and those of others. (As in, 'there's nothing wrong with a good spanking. I got hit and it made me the success I am today'.)

Parents who are preoccupied with their own trauma, such as domestic abuse or rape or the recent death of a parent or sibling, may also be too emotionally unstable and inconsistent to offer much comfort and protection. While all parents need all the help they can get to raise secure children, traumatised parents, in particular, need help to be attuned to their children's needs.

Children whose fathers had PTSD showed behavioural problems as well... this effect was indirect and was transmitted via the mother. (Living with an irascible, withdrawn or terrified spouse is likely to impose a major psychological burden on the partner.)

If you conclude that you must be a terrible person (because why else would your parents have treated you that way?), you start expecting other people to treat you horribly. You probably deserve it, and anyway, there is nothing you can do about it.

Bowlby wrote: 'What cannot be communicated to the [m]other cannot be communicated to the self.'

The cost of abuse and neglect

Our study showed that, on a deep level, the bodies of incest victims have trouble distinguishing between danger and safety.

... But if we are abused or ignored in childhood, or grow up in a family where sexuality is treated with disgust, our inner map contains a different message. Our sense of self is marked by contempt and humiliation, and we are more like to ... fail to protest if we are mistreated.

Our earliest caregivers don't only feed us, dress us, and comfort us; they shape the way our rapidly growing brain perceives reality.

Her immune system, her muscles, and her fear system all had kept the score, but her conscious mind lacked a story that could communicate that experience.

Children have no choice but to organise themselves to survive within the families they have.

Terror increases the need for attachment, even if the source of comfort is also the source of terror.

In order to know who we are - to have an identity - we must know (or at least feel that we know) what is and what was 'real'. Losing the ability to make these distinctions is one sign of what psychoanalyst William Niederland called 'soul murder'. Erasing awareness and cultivating denial are often essential to survival, but the price is that you lose track of who you are, what you are feeling, and of what and whom you can trust.

The consequences of caretaker abuse and neglect are vastly more common and complex than the impact of hurricanes or motor vehicles accidents... To this day, the DSM and the entire system based on it fail victims of child abuse and neglect.

Developmental trauma: the hidden epidemic

Sexually abused girls have an entirely different developmental pathway... The abused, isolated girls with incest histories mature sexually a year and a half earlier. Sexual abuse speeds up their biological clocks and the secretion of sex hormones.

(We need) to focus research and treatment... on the central principles that underlie the protean symptoms of chronically traumatised children and adults: pervasive biological and emotional regulation, failed or disrupted attachment, problems staying focused and on track, and a hugely deficient sense of coherent personal identity and competence.

Social support is a biological necessity, not an option, and this reality should be the backbone of all prevention and treatment.

James Heckman, winner of the 2000 Nobel Prize in Economics, has shown that quality early-childhood programs that involve parents and promote basic skills in disadvantaged children more than pay for themselves in improved outcomes.

Economists have calculated that every dollar invested in high-quality home visitation, day care, and preschool programs results in seven dollars of savings on welfare payments, health-care costs, substance-abuse treatment, and incarceration, plus higher tax revenues due to better-paying jobs.

Paths to recovery

... We can directly train our arousal system by the way we breathe, chant, and move, a principle that has been utilised since time immemorial in places like China and India, but that is suspiciously eyed as 'alternative' in mainstream [Western] culture.

In contrast to the Western reliance on drugs and verbal therapies, other traditions from around the world rely on mindfulness, movement, rhythms and action... the cultivation of purposeful movement and being centred in the present.

Mindfulness puts us in touch with the transitory nature of our feelings and perceptions. When we pay focused attention to our bodily sensations, we can recognise the ebb and flow of our emotions and, with that, increase our control over them.

Becoming aware of how your body organises particular emotions or memories opens up the possibility of releasing sensations and impulses you once blocked in order to survive.

Traumatised human beings recover in the context of relationships: families, loved ones, AA meetings, veterans' organisations, religious communities, or professional therapists. Recovery from trauma involves reconnecting with our fellow human beings.

While human contact and attunement are the wellsprings of physiological self-regulation, the promise of closeness often evokes fear of getting hurt, betrayed, and abandoned. Shame plays an important role in this. 'You will... dump me as soon as you really get to know me.' Unresolved trauma can take a terrible toll on relationships... You are likely to be preoccupied with not getting hurt again and fear opening up to someone new. In fact, you may unwittingly try to hurt them before they have a chance to hurt you.

This poses a real challenge for recovery. Once you recognise that posttraumatic reactions started off as efforts to save your life, you may gather the courage to face your inner music, but you will need help to do so... You need a guide who is not afraid of your terror... someone who can safeguard the wholeness of you while you explore the fragmented experiences that you had to keep secret from yourself for so long.

MDMA... decreases fear, defensiveness and numbing, as well as helping to access inner experience.

In trauma the self-system breaks down, and parts of the self become polarised and go to war with one another. Self-loathing coexists (and fights) with grandiosity, loving care with hatred, numbing and passivity with rage and aggression.

Mindfulness not only makes it possible to survey our internal landscape with compassion and curiosity but can also actively steer us in the right direction for self-care.

Filling in the holes

It is one thing to process memories of trauma, but it is an entirely different matter to confront the inner void - the holes in the soul that result from not having been wanted, not having been seen, and not having been allowed to speak the truth.

How can we help people become viscerally acquainted with feelings that were lacking early in their lives?

... In order to become self-confident and capable adults, it helps enormously to have grown up with steady and predictable parents; parents who delighted in you, in your discoveries and explorations, parents who helped you organise your comings and goings, and who served as role models for self-care and getting along with other people.

The more early pain and deprivation we have experienced, the more likely we are to interpret other people's actions as being directed against us and the less understanding we will be of their struggles, insecurities and concerns. If we cannot appreciate the complexity of their lives, we may see anything they do as a confirmation that we are going to get hurt and disappointed.

Finding your voice

Our sense of agency, how much we feel in control, is defined by our relationship with our bodies and its rhythms... In order to find our voice, we have to be in our bodies - able to breathe fully and able to access our inner sensations. This is the opposite of dissociation.

Along with language, dancing, marching and singing are uniquely human ways to install a sense of hope and courage.

As a culture we are trained to cut ourselves off from the truth of what we're feeling.

Traumatised people are terrified to feel deeply. They are afraid to experience their emotions, because emotions lead to loss of control... Theatre offers a unique way to access a full range of emotions and physical sensations that not only put them in touch with the habitual 'set' of their bodies, but also let them explore alternative ways of engaging with life.

Epilogue

Advantages in neuroscience have given us a better understanding of how trauma changes brain development, self-regulation, and the capacity to stay focused and in tune with others.

[In the USA]... the stubborn opposition to universal healthcare in some quarters... psychiatry's obtuse refusal to make the connection between psychic suffering and social conditions...

I wish I could separate trauma from politics, but as long as we continue to live in denial and treat only trauma while ignoring its origins, we are bound to fail. Child abuse and neglect is the single most preventable cause of mental illness, the single most common cause of drug and alcohol abuse, and a significant contributor to leading causes of death such as diabetes, heart disease, cancer, stroke and suicide.

Many of the children we work with have never been able to communicate successfully with language, as they are accustomed to adults who yell, command, sulk, or put earplugs in their ears.

Emotional intelligence starts with labelling your own feelings and attuning to the emotions of the people around you. Resilience is the product of agency: knowing that what you do can make a difference.