The Body Keeps the Score - by Bessel van der Kolk
The Body Keeps the Score - by Bessel van der Kolk
The traumatic experience influences us all. It is in our own hands to make things right again, not the doctors or the medicine they prescribe. Meditation by looking inward is helpful: “Sensing, naming, and identifying what is going on inside is the first step to recovery.” The book also got me interested in Yoga, which strengthens the connection between the mind and the body.
P.S. James Pennebaker was mentioned, and I felt I had seen this name elsewhere. Then I found Professor Pennebaker is involved with developing a popular language processing tool called LIWC.
Here are some text that I highlighted in the book:
It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability.
the birth of three new branches of science has led to an explosion of knowledge about the effects of psychological trauma, abuse, and neglect. Those new disciplines are neuroscience, the study of how the brain supports mental processes; developmental psychopathology, the study of the impact of adverse experiences on the development of mind and brain; and interpersonal neurobiology, the study of how our behavior influences the emotions, biology, and mind-sets of those around us.
We can now develop methods and experiences that utilize the brain’s own natural neuroplasticity to help survivors feel fully alive in the present and move on with their lives. There are fundamentally three avenues: 1) top down, by talking, (re-) connecting with others, and allowing ourselves to know and understand what is going on with us, while processing the memories of the trauma; 2) by taking medicines that shut down inappropriate alarm reactions, or by utilizing other technologies that change the way the brain organizes information, 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.
Trying to conceal my irritation, I asked him why. “I realized that if I take the pills and the nightmares go away,” he replied, “I will have abandoned my friends, and their deaths will have been in vain. I need to be a living memorial to my friends who died in Vietnam.” I was stunned: Tom’s loyalty to the dead was keeping him from living his own life, just as his father’s devotion to his friends had kept him from living.
How do horrific experiences cause people to become hopelessly stuck in the past? What happens in people’s minds and brains that keeps them frozen, trapped in a place they desperately wish to escape?
posttraumatic stress disorder—PTSD.
We had only one real textbook, he said: our patients.
Trauma, whether it is the result of something done to you or something you yourself have done, almost always makes it difficult to engage in intimate relationships.
Whether the trauma had occurred ten years in the past or more than forty, my patients could not bridge the gap between their wartime experiences and their current lives. Somehow the very event that caused them so much pain had also become their sole source of meaning. They felt fully alive only when they were revisiting their traumatic past.
Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think.
For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present.
the job of therapists is to help people “acknowledge, experience, and bear” the reality of life—with all its pleasures and heartbreak.
the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), which is commonly referred to as the “bible of psychiatry.” The foreword to the landmark 1980 DSM-III was appropriately modest and acknowledged that this diagnostic system was imprecise—so imprecise that it never should be used for forensic or insurance purposes. As we will see, that modesty was tragically short-lived.
traumatized people keep secreting large amounts of stress hormones long after the actual danger has passed
the only way to teach the traumatized dogs to get off the electric grids when the doors were open was to repeatedly drag them out of their cages so they could physically experience how they could get away
ADDICTED TO TRAUMA: THE PAIN OF PLEASURE AND THE PLEASURE OF PAIN
The study was blinded: Neither we nor the patients knew which substance they were taking, so that our preconceptions could not skew our assessments.
After conducting numerous studies of medications for PTSD, I have come to realize that psychiatric medications have a serious downside, as they may deflect attention from dealing with the underlying issues. The brain-disease model takes control over people’s fate out of their own hands and puts doctors and insurance companies in charge of fixing their problems.
Half a million children in the United States currently take antipsychotic drugs. Children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines.
our capacity to destroy one another is matched by our capacity to heal one another.
When something reminds traumatized people of the past, their right brain reacts as if the traumatic event were happening in the present. But because their left brain is not working very well, they may not be aware that they are reexperiencing and reenacting the past—they are just furious, terrified, enraged, ashamed, or frozen.
No matter how much insight and understanding we develop, the rational brain is basically impotent to talk the emotional brain out of its own reality. I am continually impressed by how difficult it is for people who have gone through the unspeakable to convey the essence of their experience. It is so much easier for them to talk about what has been done to them—to tell a story of victimization and revenge—than to notice, feel, and put into words the reality of their internal experience.
As long as their caregivers remain calm and responsive to their needs, they often survive terrible incidents without serious psychological scars.
Healing from PTSD means being able to terminate this continued stress mobilization and restoring the entire organism to safety.
Immobilization keeps the body in a state of inescapable shock and learned helplessness.
Any effective treatment for trauma has to address these basic housekeeping functions of the body.
If you feel safe and loved, your brain becomes specialized in exploration, play, and cooperation; if you are frightened and unwanted, it specializes in managing feelings of fear and abandonment.
Constantly fighting unseen dangers is exhausting and leaves them fatigued, depressed, and weary.
Sensing, naming, and identifying what is going on inside is the first step to recovery.
Trauma is the ultimate experience of “this will last forever.”
Being anchored in the present while revisiting the trauma opens the possibility of deeply knowing that the terrible events belong to the past. For that to happen, the brain’s watchtower, cook, and timekeeper need to be online. Therapy won’t work as long as people keep being pulled back into the past.
Being able to feel safe with other people is probably the single most important aspect of mental health; safe connections are fundamental to meaningful and satisfying lives. Numerous studies of disaster response around the globe have shown that social support is the most powerful protection against becoming overwhelmed by stress and trauma. Social support is not the same as merely being in the presence of others. The critical issue is reciprocity: being truly heard and seen by the people around us, feeling that we are held in someone else’s mind and heart.
Well-functioning people are able to accept individual differences and acknowledge the humanity of others.
Yelling at someone who is already out of control can only lead to further dysregulation. Just as your dog cowers if you shout and wags his tail when you speak in a high singsong, we humans respond to harsh voices with fear, anger, or shutdown and to playful tones by opening up and relaxing. We simply cannot help but respond to these indicators of safety or danger.
In response to the trauma itself, and in coping with the dread that persisted long afterward, these patients had learned to shut down the brain areas that transmit the visceral feelings and emotions that accompany and define terror. Yet in everyday life, those same brain areas are responsible for registering the entire range of emotions and sensations that form the foundation of our self-awareness, our sense of who we are. What we witnessed here was a tragic adaptation: In an effort to shut off terrifying sensations, they also deadened their capacity to feel fully alive.
Yet our conscious self also plays a vital role in maintaining our inner equilibrium: We need to register and act on our physical sensations to keep our bodies safe.
However, traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs, and, in an attempt to control these processes, they often become expert at ignoring their gut feelings and in numbing awareness of what is played out inside. They learn to hide from their selves. The more people try to push away and ignore internal warning signs, the more likely they are to take over and leave them bewildered, confused, and ashamed. People who cannot comfortably notice what is going on inside become vulnerable to respond to any sensory shift either by shutting down or by going into a panic—they develop a fear of fear itself.
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.
Many of my patients respond to stress not by noticing and naming it but by developing migraine headaches or asthma attacks.
Suppressing our inner cries for help does not stop our stress hormones from mobilizing the body.
Somatic symptoms for which no clear physical basis can be found are ubiquitous in traumatized children and adults. They can include chronic back and neck pain, fibromyalgia, migraines, digestive problems, spastic colon/irritable bowel syndrome, chronic fatigue, and some forms of asthma. Traumatized children have fifty times the rate of asthma as their nontraumatized peers. Studies have shown that many children and adults with fatal asthma attacks were not aware of having breathing problems before the attacks.
Many traumatized children and adults simply cannot describe what they are feeling because they cannot identify what their physical sensations mean. They tend to register emotions as physical problems rather than as signals that something deserves their attention.
The more people were out of touch with their feelings, the less activity they had in the self-sensing areas of the brain. Because traumatized people often have trouble sensing what is going on in their bodies, they lack a nuanced response to frustration. They either react to stress by becoming “spaced out” or with excessive anger. Whatever their response, they often can’t tell what is upsetting them. This failure to be in touch with their bodies contributes to their well-documented lack of self-protection and high rates of revictimization23 and also to their remarkable difficulties feeling pleasure, sensuality, and having a sense of meaning.
Physical self-awareness is the first step in releasing the tyranny of the past.
How can people open up to and explore their internal world of sensations and emotions? In my practice I begin the process by helping my patients to first notice and then describe the feelings in their bodies—not emotions such as anger or anxiety or fear but the physical sensations beneath the emotions: pressure, heat, muscular tension, tingling, caving in, feeling hollow, and so on. I also work on identifying the sensations associated with relaxation or pleasure. I help them become aware of their breath, their gestures and movements. I ask them to pay attention to subtle shifts in their bodies, such as tightness in their chests or gnawing in their bellies, when they talk about negative events that they claim did not bother them.
All too often, however, drugs such as Abilify, Zyprexa, and Seroquel, are prescribed instead of teaching people the skills to deal with such distressing physical reactions. Of course, medications only blunt sensations and do nothing to resolve them or transform them from toxic agents into allies.
To have genuine relationships you have to be able to experience others as separate individuals, each with his or her particular motivations and intentions. While you need to be able to stand up for yourself, you also need to recognize that other people have their own agendas. Trauma can make all that hazy and gray.
In card after card we saw that, despite their alertness to trouble, the children who had not been abused still trusted in an essentially benign universe; they could imagine ways out of bad situations. They seemed to feel protected and safe within their own families. They also felt loved by at least one of their parents, which seemed to make a substantial difference in their eagerness to engage in schoolwork and to learn.
Is it possible to help the minds and brains of brutalized children to redraw their inner maps and incorporate a sense of trust and confidence in the future?
how human beings may be induced to sacrifice everything they hold dear and true—including their sense of self—for the sake of being loved and approved of by someone in a position of authority.
In contrast, children with histories of abuse and neglect learn that their terror, pleading, and crying do not register with their caregiver. Nothing they can do or say stops the beating or brings attention and help. In effect they’re being conditioned to give up when they face challenges later in life.
Looking at this spectrum of angry to sad expressions, the abused kids were hyperalert to the slightest features of anger.
People who cannot connect through work, friendships, or family usually find other ways of bonding, as through illnesses, lawsuits, or family feuds. Anything is preferable to that godforsaken sense of irrelevance and alienation.
With “good enough” caregivers, children learn that broken connections can be repaired. The critical issue is whether they can incorporate a feeling of being viscerally safe with their parents or other caregivers.
Similarly, the reactions of children to painful events are largely determined by how calm or stressed their parents are.
Emotional distance and role reversal (in which mothers expected the kids to look after them) were specifically linked to aggressive behavior against self and others in the young adults.
Being in synch means resonating through sounds and movements that connect, which are embedded in the daily sensory rhythms of cooking and cleaning, going to bed and waking up. Being in synch may mean sharing funny faces and hugs, expressing delight or disapproval at the right moments, tossing balls back and forth, or singing together.
The DSM definition of PTSD is quite straightforward: A person is exposed to a horrendous event “that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” causing “intense fear, helplessness, or horror,” which results in a variety of manifestations: intrusive reexperiencing of the event (flashbacks, bad dreams, feeling as if the event were occurring), persistent and crippling avoidance (of people, places, thoughts, or feelings associated with the trauma, sometimes with amnesia for important parts of it), and increased arousal (insomnia, hypervigilance, or irritability). This description suggests a clear story line: A person is suddenly and unexpectedly devastated by an atrocious event and is never the same again. The trauma may be over, but it keeps being replayed in continually recycling memories and in a reorganized nervous system
We remember insults and injuries best: The adrenaline that we secrete to defend against potential threats helps to engrave those incidents into our minds. Even if the content of the remark fades, our dislike for the person who made it usually persists.
If the problem with PTSD is dissociation, the goal of treatment would be association: integrating the cut-off elements of the trauma into the ongoing narrative of life, so that the brain can recognize that “that was then, and this is now.”
As long as a memory is inaccessible, the mind is unable to change it. But as soon as a story starts being told, particularly if it is told repeatedly, it changes—the act of telling itself changes the tale. The mind cannot help but make meaning out of what it knows, and the meaning we make of our lives changes how and what we remember.
This combination of core strengthening—psychological, social, and physical—created a sense of personal safety and mastery, relegating my memories to the distant past, allowing the present and future to emerge.”
The challenge of recovery is to reestablish ownership of your body and your mind—of your self. This means feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed. For most people this involves (1) finding a way to become calm and focused, (2) learning to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind you of the past, (3) finding a way to be fully alive in the present and engaged with the people around you, (4) not having to keep secrets from yourself, including secrets about the ways that you have managed to survive.
the only way we can consciously access the emotional brain is through self-awareness, i.e. by activating the medial prefrontal cortex, the part of the brain that notices what is going on inside us and thus allows us to feel what we’re feeling. (The technical term for this is “interoception”—Latin for “looking inside.”) Most of our conscious brain is dedicated to focusing on the outside world: getting along with others and making plans for the future. However, that does not help us manage ourselves. Neuroscience research shows that the only way we can change the way we feel is by becoming aware of our inner experience and learning to befriend what is going inside ourselves.
Some 80 percent of the fibers of the vagus nerve (which connects the brain with many internal organs) are afferent; that is, they run from the body into the brain. This means that we can directly train our arousal system by the way we breathe, chant, and move, a principle that has been utilized since time immemorial in places like China and India, and in every religious practice that I know of, but that is suspiciously eyed as “alternative” in mainstream culture.
Study after study shows that having a good support network constitutes the single most powerful protection against becoming traumatized. Safety and terror are incompatible.
Frightened adults respond to the same comforts as terrified children: gentle holding and rocking and the assurance that somebody bigger and stronger is taking care of things, so you can safely go to sleep. In order to recover, mind, body, and brain need to be convinced that it is safe to let go. That happens only when you feel safe at a visceral level and allow yourself to connect that sense of safety with memories of past helplessness.
If the people whom you naturally turn to for care and protection terrify or reject you, you learn to shut down and to ignore what you feel. As we saw in part 3, when your caregivers turn on you, you have to find alternative ways to deal with feeling scared, angry, or frustrated. Managing your terror all by yourself gives rise to another set of problems: dissociation, despair, addictions, a chronic sense of panic, and relationships that are marked by alienation, disconnection, and explosions.
The critical question is this: Do you feel that your therapist is curious to find out who you are and what you, not some generic “PTSD patient,” need? Are you just a list of symptoms on some diagnostic questionnaire, or does your therapist take the time to find out why you do what you do and think what you think? Therapy is a collaborative process—a mutual exploration of your self.
we can take drugs that blunt our emotions or we can learn to desensitize ourselves.
Getting perspective on your terror and sharing it with others can reestablish the feeling that you are a member of the human race.
Stories can also provide people with a target to blame. Blaming is a universal human trait that helps people feel good while feeling bad, or, as my old teacher Elvin Semrad used to say: “Hate makes the world go round.”
There are other ways to access your inner world of feelings. One of the most effective is through writing. When we talk with someone with whom we don’t feel completely safe, our social editor jumps in on full alert and our guard is up. Writing is different.
the object of writing is to write to yourself, to let your self know what you have been trying to avoid.
marathon running markedly increased HRV(heart rate variability ).
HRV in PTSD. Breathing is rapid and shallow. Heart rate is slow and out of synch with the breath. This is a typical pattern of a shut-down person with chronic PTSD.
We do not truly know ourselves unless we can feel and interpret our physical sensations; we need to register and act on these sensations to navigate safely through life.
dissociative identity disorder (DID), which at that time was called multiple personality disorder.
How well we get along with ourselves depends largely on our internal leadership skills—how well we listen to our different parts, make sure they feel taken care of, and keep them from sabotaging one another.
Most of the men I evaluated with regard to their childhood molestation by Catholic priests took anabolic steroids and spent an inordinate amount of time in the gym pumping iron. These compulsive bodybuilders lived in a masculine culture of sweat, football, and beer, where weakness and fear were carefully concealed. Only after they felt safe with me did I meet the terrified kids inside.
The first step in this collaboration is to assure the internal system that all parts are welcome and that all of them—even those that are suicidal or destructive—were formed in an attempt to protect the self-system, no matter how much they now seem to threaten it.
What happens when the self is no longer in charge? IFS calls this “blending”: a condition in which the Self identifies with a part, as in “I want to kill myself” or “I hate you.” Notice the difference from “A part of me wishes that I were dead” or “A part of me gets triggered when you do that and makes me want to kill you.”
his confidence had crossed the line into arrogance.
If your parents’ faces never lit up when they looked at you, it’s hard to know what it feels like to be loved and cherished. If you come from an incomprehensible world filled with secrecy and fear, it’s almost impossible to find the words to express what you have endured. If you grew up unwanted and ignored, it is a major challenge to develop a visceral sense of agency and self-worth.
Children who have not been allowed to assert themselves will probably have difficulty standing up for themselves as adults, and most grown-ups who were brutalized as children carry a smoldering rage that will take a great deal of energy to contain.
Acting is not about putting on a character but discovering the character within you: you are the character, you just have to find it within yourself—albeit a very expanded version of yourself.
music, theater, art, and sports—timeless ways of fostering competence and collective bonding—continue to disappear from our schools.
When I give presentations on trauma and trauma treatment, participants sometimes ask me to leave out the politics and confine myself to talking about neuroscience and therapy. 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. In today’s world your ZIP code, even more than your genetic code, determines whether you will lead a safe and healthy life. People’s income, family structure, housing, employment, and educational opportunities affect not only their risk of developing traumatic stress but also their access to effective help to address it. Poverty, unemployment, inferior schools, social isolation, widespread availability of guns, and substandard housing all are breeding grounds for trauma. Trauma breeds further trauma; hurt people hurt other people.
Resilience is the product of agency: knowing that what you do can make a difference.
Athletics, playing music, dancing, and theatrical performances all promote agency and community.