Brain, Mind, and Body in the Healing of Trauma
Reading a 400+ page book on the healing of trauma may not sound like a lot of fun, but reading a brilliantly written, best-book-in-the-field-ever book on tools and techniques to help people fully recover an authentic self and deep joy in feeling fully alive can be completely inspiring.
I read Bessel van der Kolk’s best-selling The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma on the long flight home from teaching in Australia three weeks ago, teaching clinicians about the healing of attachment trauma, and my own knowledge – and gratitude for the learning – expanded ten-fold.
Dr. Bessel van der Kolk has been a pioneering researcher and inquisitive practicing clinician in the field of trauma therapy for 30 years, founder and medical director of the Trauma Center in Brookline, MA, treating thousands of patients and training hundreds of clinicians, discovering and teaching tools that are effective in helping survivors “feel fully alive in the present and move on with their lives.”
You many wonder why you would want to read this newsletter. Trauma is a heavy topic and the mental health field has been stumbling around in the dark about it for more than a century.
But trauma is rather ubiquitous.
“One does not have to be a combat soldier, or visit a refugee camp in Syria or the Congo to encounter trauma. Trauma happens to us, our friends, our families, and our neighbors.”
And with the discoveries of modern neuroscience and behavioral science, there is real hope.
“Since the early 1990s, brain-imaging tools have started to show us what actually happens inside the brains of traumatized people. This has proven essential to understanding the damage inflicted by trauma and has guided us to formulate entirely new avenues of repair. 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.”
It’s those deeper layers of brain, mind and body that interest me as a psychotherapist and as a human being. A memory of being made fun of in the third grade pops into my mind suddenly, with all the feelings and hurts of that moment – why can’t I get over this already? And the universality of that experience.
Does everyone in the world experience trauma? Chances are, yes. Certainly everybody knows somebody in their 3-degrees of separation. And that’s why I’m taking the time to read Dr. van der Kolk’s book (twice) and glean from it some of the findings that illuminate and transform our understanding of trauma and its healing.
Dr. van der Kolk’s book is comprehensive, very clearly written; many clients recommended it to me, having found great clarity in it for their own journey.
In the Reflections below, I have focused on the impact of trauma on the brain, the body, on memory, on the self, and on connections to others. [Everything directly quoted from The Body Keeps the Score – easy to read.) In the Exercises to Practice section, I have highlighted some of the many well-researched treatment modalities available now, including some – yoga, theater, neurofeedback – you might not expect.
Please try. At least save the newsletter to read for the day when you might suspect that the insomnia, anxiety, depression, emotional distancing, lack of meaning, direction or purpose you or someone close to you is experiencing might have root causes in an even unremembered previous trauma.
There is real, real hope.
THE IMPACT OF TRAUMA ON THE BRAIN
Identifying Danger: The Cook, the Smoke Detector, the Watchtower, the Timekeeper
Danger is a normal part of life, and the brain is in charge of detecting it and organizing our response. Sensory information about the outside world arrives through our eyes, nose, ears, and skin. These sensations converge in the thalamus, an area inside the limbic system that acts as the “cook” within the brain. The thalamus stirs all the input from our perceptions into a fully blended autobiographical soup, an integrated, coherent experience of “this is what is happening to me”.
The sensations are then passed on in two directions – down to the amygdala, two small almond-shaped structures that lie deeper in the limbic unconscious brain, and up to the frontal lobes, where they reach our conscious awareness. The neuroscientist Joseph LeDoux calls the pathway to the amygdala “the low road,” which is extremely fast, and that to the front cortex the “high road,” which takes several milliseconds longer in the midst of an overwhelmingly threatening experience.
However, processing by the thalamus can break down. Sights, sounds, smells and touch are encoded as isolated, dissociated fragments, and normal memory processing disintegrates. Time freezes, so that the present danger feels like it will last forever.
The central function of the amygdala, which I call the brain’s smoke detector, is to identify whether incoming input is relevant for our survival. It does so quickly and automatically, with the help of feedback from the hippocampus, a nearby structure that relates the new input to past experiences. If the amygdala senses a threat – a potential collision with an oncoming vehicle, a person on the street who looks threatening – 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. Because the amygdala processes the information it receives from the thalamus faster than the frontal lobes do, it decides whether incoming information is a threat to our survival even before we are consciously aware of the danger. By the time we realize what is happening, our body may already be on the move.
The amygdala’s danger signals trigger the release of powerful stress hormones, including cortisol and adrenaline, which increase hart rate, blood pressure, and rate of breathing, preparing us to fight back or run away. 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.
While the smoke detector is usually pretty good at picking up danger clues, trauma increases the risk of misinterpreting whether a particular situation is dangerous or safe. You can get along with other people only if you can accurately gauge whether their intentions are benign or dangerous. Even a slight misreading can lead to painful misunderstandings in relationships at home and at work. 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 behavior accordingly. Faulty alarm systems lead to blowups or shutdowns in response to innocuous comments or facial expressions.
If the amygdala is the smoke detector in the brain, think of the frontal lobes – and specifically the medial prefrontal cortex (mPFC), located directly above our eyes, as the watchtower, offering a view of the scene from on high. Is that smoke you smell the sign that your house is on fire and you need to get out, fast – or is it coming from the steak you put over too high a flame? The amygdala doesn’t make such judgments; it just gets you ready to fight back or escape, even before the frontal lobes get a chance to weigh in with their assessment. As long as you are not too upset, your frontal lobes can restore your balance by helping you realize that you are responding to a false alarm and abort the stress response.
Ordinarily the executive capacities of the prefrontal cortex enable people to observe what is going on, predict what will happen if you take a certain action, and make a conscious choice. Being able to hover calmly and objectively over our thoughts, feelings, and emotions (an ability called mindfulness) and then take our time to respond allows the executive brain to inhibit, organize, and modulate the hardwired automatic reactions pre-programmed into the emotional brain. This capacity is crucial for preserving our relationship with our fellow human beings. As long as our frontal lobes are working properly, we’re unlikely to lose our temper every time a waiter is late with our order or an insurance company agent puts us on hold. (Our watchtower also tells us that other people’s anger and threats are a function of their emotional state.) When that system breaks down, we become like conditioned animals. The moment we detect danger we automatically go into fight-or-flight mode.
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. The more intense the visceral sensory input from the emotional brain, the less capacity the rational brain has to put a damper on it. If the interpretation of threat by the amygdala is too intense, and/or the filtering system from the higher areas of the brain are too weak, as often happens in PTSD, people lose control over automatic emergency responses, like prolonged startle or aggressive outbursts.
Neuroimaging studies of human beings in highly emotional states reveal that intense fear, sadness, and anger all increase the activation of lower brain regions involved in emotions and significantly reduce the activity in various areas in the frontal lobe (higher brain) particularly the MPFC. When that occurs, the inhibitory capacitors of the frontal lobe break down, and people “take leave of their senses” they may startle in response to any loud sound, become enraged by small frustrations, or freeze when somebody touches them.
Effectively dealing with stress depends upon achieving a balance between the smoke detector and the watchtower. If you want to manage your emotions better, your brain gives you two options: You can learn to regulate them from the top down or from the bottom up.
Knowing the difference between top down and bottom up regulation is central for understanding and treating traumatic stress. Top-down regulation involves strengthening the capacity of the watchtower to monitor your body’s sensations. Mindfulness and yoga can help with this. Bottom-up regulation involves recalibrating the autonomic nervous system, which originates in the brain stem. We can access the ANS through breath, movement, or touch.
It’s important to have an efficient smoke detector. You don’t want to get caught unawares by a raging fire. But if you go into a frenzy every time you smell smoke, it becomes intensely disruptive. Yes, you need to detect whether somebody is getting upset with you, but if your amygdala goes into overdrive, you may become chronically scared that people hate you, or you may feel like they are out to get you.
Two brain systems are relevant to the mental processing of trauma: those dealing with emotional intensity and context. Emotional intensity is defined by the smoke alarm, the amygdala, and its counterweight, the watchtower, the medial prefrontal cortex. The context and meaning of an experience are determined by the system that includes the dorsolateral prefrontal cortex (dlPFC) and the hippocampus. The dlPFCis located to the side in the front brain, while the mPFC is in the center. The structure along the midline of the brain are devoted to your inner experience of yourself, those on the side are more concerned with your relationship with your surroundings.
The dlPFC tells us how our present experience relates to the past and how it may affect the future – you can think of it as the timekeeper of the brain. Knowing that whatever is happening is finite and will sooner or later come to an end makes most experiences tolerable. The opposite is also true – situations become intolerable if they feel interminable. Most of us know from sad personal experience that terrible grief is typically accompanied by the sense that this wretched state will last forever, and that we will never get over our loss. Trauma is the ultimate experience of “this will last forever.”
People can recover from trauma only when the brain structures that were knocked out during the original experience – which is why the event registered in the brain as trauma in the first place – are fully online. Visiting the past in therapy should be done while people are, biologically speaking, firmly rooted in the present and feeling as calm, safe, and grounded as possible. (“Grounded” means that you can feel your butt in the chair, see the light coming through the window, feel the tension in your calves, and hear the wind stirring the tree outside.) 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.
[In exercises to Practice, I offer examples of both top-down and bottom-up strategies for healing from trauma.]
Images of past trauma activate the right hemisphere of the brain and deactivate the left. 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 half of the brain does all the talking, the right half of the brain 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 experiences to others.
The left and right sides of the brain also process the imprints of the past in dramatically different ways. The left brain remembers facts, statistics, and the vocabulary of events. We call on it to explain our experiences and put them in order. The right brain stores memories of sound, touch, small, and the emotions they evoke. It reacts automatically to voices, facial features, and gestures and places experienced in the past. What it recalls feels like “intuitive truth” – the way things are.
Deactivation of the left hemisphere has a direct impact on the capacity to organize experience into logical sequences and to translate our shifting feelings and perceptions into words. Broca’s area, which blacks out during flashbacks, is on the left side.
[Here’s a sidebar about Broca’s area: Without a functioning Broca’s area, you cannot put your thoughts and feelings into words. Even years later traumatized people often have enormous difficulty telling other people what has happened to them. Their bodies re-experience terror, rage, and helplessness, as well as the impulse to fight or flee, but these feelings are almost impossible to articulate.
This doesn’t mean that people can’t talk about a tragedy that has befallen them. Sooner or later most survivors come up with what many of them call their “cover story” that offers some explanation for their symptoms and behavior for public consumption. These stories, however, rarely capture the inner truth of the experience. It is enormously difficult to organize one’s traumatic experiences into a coherent account – a narrative with a beginning, a middle, and an end. Even a seasoned reporter like the famed CBS correspondent Ed Murrow struggled to convey the atrocities he saw when the Nazi concentration camp Buchenwald was liberated in 1945: “I pray you believe what I have said. I reported what I saw and hear, but only part of it. For most of it I have no words.”]
Without sequencing we can’t identify cause and effect, grasp the long-term effects of our actions, or create coherent plans for the future. People who are very upset sometimes say they are “losing their minds.” In technical terms they are experiencing the loss of executive functioning.
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 re-experiencing and re-enacting the past – they are just furious, terrified, enraged, ashamed, or frozen. After the emotional storm passes, they may look for something or somebody to blame to it. They behaved the way they did because you were ten minutes late, or because you burned the potatoes, or because you never listen to me. Of course, most of us have done this from time to time, but when we cool down, we hopefully can admit our mistake. Trauma interferes with this kind of awareness.
IMPACT OF TRAUMA ON THE BODY
Adrenaline is one of the hormones that are critical to help us fight back or flee in the face of danger. Under normal conditions people react to a threat with a temporary increase in their stress hormones. As soon as the threat is over, the hormones dissipate and the body returns to normal. The stress hormones of traumatized people, in contrast, take much longer to return to baseline and spike quickly and disproportionately in response to mildly stressful stimuli. The insidious effects of constantly elevated stress hormones include memory and attention problems, irritability, and sleep disorders.
We now know that there is another possible response to threat, which our scans aren’t yet capable of measuring. Some people simply go into denial. Their bodies register the threat, but their conscious minds go on as if nothing has happened. However, even though the mind may learn to ignore the 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 immobilize 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 sensation or feelings. But the body continues to keep the score.
People in trauma are rarely in touch with the fact that these sensations have their origins in traumatic experiences. That is where therapy comes in – therapists can assist people to mindfully observe their emotions and sensations and help them get in touch with the context from which they emerge. However, the bottom line is that the threat-perception system of the brain has changed, and people’s physical reactions are dictated by the imprint of the past.
THE IMPACT OF TRAUMA ON MEMORY
When people can take an active role by becoming an agent in one’s own rescue, once in a safe place, alarm bells in the brain and body quiet. Then the mind is free to make sense of what happened. If not, traumatized people become stuck, stopped in their growth because they can’t integrate new experiences into their lives. Being traumatized means continuing to organize your life as if the trauma were still going on – unchanged and immutable, as every new encounter or event is contaminated by the past.
Dissociation is the essence of trauma. The overwhelming experience is split off and fragmented, so that the emotions, sounds, images, thoughts, and physical sensations related to the trauma take on a life of their own. The sensory fragments of memory intrude into the present, where they are literally relived. As long as the trauma is not resolved, the stress hormones that the body secretes to protect itself keep circulating, and the defensive movements and emotional responses keep getting replayed.
Flashbacks and reliving are in some ways worse than the trauma itself. A traumatic event has a beginning and an end – at some point it is over. But for people with PTSD, a flashback can occur at any time, whether they are awake or asleep. There is no way of knowing when it’s going to occur again or how long it will last. People who suffer from flashbacks often organize their lives around trying to protect against them. The may compulsively go to the gym to pump iron, numb themselves with drugs, or try to cultivate an illusory sense of control in highly dangerous situations like motorcycle racing, bungee jumping, or working as an ambulance driver.
If elements of the trauma are replayed again and again, the accompanying stress hormones engrave those memories every more deeply in the mind. Ordinary, day-to-day events become less and less compelling. Not being able to deeply take in what is going on around them makes it impossible to feel fully alive. It becomes harder to feel the joys and aggravations of ordinary life, harder to concentrate on the tasks at hand. Not being fully alive in the present keeps them more firmly imprisoned in the past.
Trauma affects the entire human organism – body, mind, and brain. In PTSD the body continues to defend against a threat that belongs to the past. Healing from PTSD means being able to terminate this continued stress mobilization and restore the entire organism to safety. These attempts to maintain control over unbearable physiological reactions can result in a whole range of physical symptoms, including fibromyalgia, chronic fatigue, and other autoimmune diseases. This explains why it is critical for trauma treatment to engage the entire organism, body, mind, and brain.
The trauma that started “out there” is not played out on the battlefield of their own bodies, usually without a conscious connection between what happened back then and what is going on right now inside. The challenge is not so much learning to accept the terrible things that have happened but learning how to gain master over one’s internal sensations and emotions. Sensing, naming, and identifying what is going on inside is the first step to recovery.
THE IMPACT OF TRAUMA ON THE SENSE OF SELF
I discovered that my professional training, with its focus on understanding and insight, had largely ignored the relevance of the living, breathing body, the foundation of our selves. Once I was alerted to this, I was amazed to discover how many of my patients told me they could not feel whole areas of their bodies. Their sensory perceptions simply weren’t working. People with PTSD often have trouble putting the picture together. Scans of chronic PTSD patients with severe early-life trauma are startling. There is almost no activation of any of the self-sensing areas of the brain. The lack of self-awareness in victims of early childhood trauma is sometimes so profound that they cannot recognize themselves in a mirror. Brain scans show that this is not the result of mere inattention. The structure in charge of self-recognition may be knocked out along with the structure related to self-experience.
The elementary self system in the brain stem and limbic system is massively activated when people are faced with the threat of annihilation, which results in an overwhelming sense of fear and terror, accompanied by intense physiological arousal. To people who are reliving a trauma, nothing makes sense; they are trapped in a life-or-death situation, a state of paralyzing fear or blind rage. Mind and body are constantly aroused, as if they are in imminent danger. They startle in response to the slightest noises and are frustrated by small irritants. Their sleep is chronically disturbed, and food often loses its sensual pleasures. This in turn can trigger desperate attempts to shut those feelings down by freezing and dissociation.
“Agency” is the technical term for the feeling of being in charge of your life: knowing where you stand, knowing that you have a say in what happens to you, knowing that you have some ability to shape your circumstance. If you have a comfortable connection with your inner sensations – if you can trust them to give you accurate information – you will feel in charge of your body, your feelings, and your self.
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 mobilize 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.
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.
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 comfortable 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. People’s lives will be held hostage to fear until that visceral experience changes.
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 re-victimization and also to their remarkable difficulties feelings pleasure, sensuality, and having a sense of meaning.
Trauma victims cannot recover until they become familiar with and befriend the sensations in their bodies. Being frightened means that you live in a body that is always on guard. In order to change, people need to become aware of their sensations and the way that their bodies interact with the world around them. Physical self-awareness is the first step in releasing the tyranny of the past. The mind needs to re-educated to feel physical sensations, and the body needs to be helped to tolerate and enjoy the comforts of touch. Individuals who lack emotional awareness are able, with practice, to connect their physical sensations to psychological events. Then they can slowly reconnect with themselves.
THE IMPACT OF TRAUMA ON SENSE OF CONNECTIONS AND SAFETY
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. 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.
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. Trauma almost invariably involves not being seen, not being mirrored, and not being taken into account. Feeling listened to changes our physiology. As long as the mind is defending itself against invisible assaults, our closest bonds are treated, along with our ability to imagine, plan, play, learn, and pay attention to other people’s needs For our physiology to calm down, heal, and grow, we need a visceral feeling of safety. Treatment needs to reactivate the capacity to safely mirror and be mirrored by others
After trauma the world is experienced with a different nervous system that has an altered perception of risk and safety. Stephen Porges coined the word “neuroception” to describe the capacity to evaluate relative danger and safety in one’s environment. When we try to help people with faulty neuroception, the great challenge is finding ways to reset their physiology, so that their survival mechanisms stop working against them. This means helping them to respond appropriate to danger but, even more, to recover the capacity to experience safety, relaxation, and true reciprocity.
POETRY AND QUOTES TO INSPIRE
We also learned that trauma affects the imagination. People caught in memories of the past were not displaying the mental flexibility that is the hallmark of imagination.
Imagination is absolutely critical to the quality of our lives. Imagination fires our creativity, relieves our boredom, alleviates our pain, enhances our pleasure, and enriches our most intimate relationships. Our imagination enables us to leave our routine everyday existence by fantasizing about travel, food, sex, falling in love, or having the last word -all the things that make life interesting. Imagination gives us the opportunity to envision new possibilities – it is an essential launchpad for making our hopes come true. When people are compulsively and constantly pulled back into the past, to the last time they felt intense involvement and deep emotions, they suffer from a failure of imagination, a loss of the mental flexibility. Without imagination there is no hope, no chance to envision a better future, no place to go, no goal to reach.
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Numbing is the other side of the coin in PTSD. Many untreated trauma survivors start out with explosive flashbacks, then numb out later in life. While reliving trauma is dramatic, frightening, and potentially self-destructive, over time a lack of presence can be even more damaging. This is a particular problem with traumatized 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.
The challenge of trauma treatment is not only dealing with the past but, even more, enhancing the quality of day-to-day experience. One reason that traumatic memories become dominant in PTSD is that it’s so difficult to feel truly alive right now. When you can’t be fully here, you go to the places where you did feel alive – even if those places are filled with horror and misery.
We must most of all help our patients to live fully and securely in the present. In order to do that, we need to help bring those brain structures that deserted them when they were overwhelmed by trauma back. Desensitization may make you less reactive, but if you cannot feel satisfaction in ordinary everyday things like talking a walk, cooking a meal, or play with our kids, life will pass you by.
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“While we all want to move beyond trauma, the part of our brain that is devoted to ensuring our survival (deep below our rational brain) is not very good at denial….Trauma produces actual physiological changes, including a recalibration of the brain’s alarm system, an increase in stress hormone activity, and alternations in the system that filters relevant information from irrelevant. We now know that trauma compromise the brain area that communicates the physical, embodied feeling of being alive. Long after a traumatic experience is over, it may be reactivated at the slightest hint of danger and mobilize disturbed brain circuits and secrete massive amounts of stress hormones. This precipitates unpleasant emotions, intense physical sensations, and impulsive and aggressive actions. These changes explain why traumatized individuals become hypervigilant to threat at the expense of spontaneously engaging in their day-to-day lives. They also help us understand why traumatized people so often keep repeating the same problems and have such trouble learning from experience. We now know that their behaviors are not the result of moral failings or signs of lack of willpower or bad character – they are caused by actual changes in the brain.
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Research by the Centers for Disease Control and Prevention has shown that one in five Americans was sexually molested as a child; one in four was beating by a parent to the point of a mark being left on their body; and one in three couples engages in physical violence. A quarter of us grew up with alcoholic relatives, and one out of eight witnessed their mother being beaten or hit. More than half the people who seek psychiatric care have been assaulted, abandoned, neglected or even raped as children. For every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes.
[These realities are so heavy to hear, harder to bear, and often hidden away. We don’t want them to be true for ourselves or for anyone we know, and sometimes we just don’t want to know. This denial extends to psychiatry and the mental health field itself. Dr. van der Kolk relates:]
When I took a position at the Massachusetts Mental Health Center, the Harvard teaching hospital where I had trained to become a psychiatrist…I was particularly struck by how many female patients spoke of being sexually abused as children. This was puzzling, as the standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, occurring about once in every million women. Given that there were then only about one hundred million women living in the United States, I wondered how forty seven, almost half of them, had found their way to my office in the basement of the hospital.
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When the brain’s alarm system is turned on, it automatically triggers pre-programmed physical escape plans in the oldest parts of the brain. As in other animals, the nerves and chemicals that make up our basic brain structures have a direct connection with our body. When the older brain takes over, it partially shuts down the higher brain, our conscious mind, and propels the body to run, hide, fight, or on occasion, freeze. By the time we are fully aware of our situation, our body may already be on the move. If the fight/flight/freeze response is successful and we escape the danger. Effective action (the result of fight/flight) ends the threat. We recover our internal equilibrium and gradually “regain our senses.”
If for some reason the normal response is blocked – for example, when people are held down, trapped, or otherwise prevented from taking effective action, be it in a war zone, a car accident, domestic violence, or a rape – the brain keeps secreting stress chemical, and the brain’s electrical circuits continue to fire in vain. Immobilization keeps the body in a state of inescapable shock and learned helplessness. Long after the actual event has passed, the brain may keep sending signals to the body to escape a threat that no longer exists.
Brain and body are programmed to run for home, where safety can be restored and stress hormones can come to rest. When stress hormone levels remain elevated, they are turned against the survivors, stimulating ongoing fear, depression, rage, and physical disease.
This bidirectional communication between body and mind was largely ignored by Western science, even as it had long been central to traditional healing practices in many other parts of the world, notable in India and China. Today it is transforming our understanding of trauma and recovery.
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Breathing, eating, sleeping, pooping, and peeing are so fundamental that their significance is easily neglected when we’re considering the complexities of mind and behavior. However, if your sleep is disturbed or your bowels don’t works, or if you always feel hungry, or if being touched makes you want to scream (as is often the case with traumatized children and adults) the entire organism is through into disequilibrium. It is amazing how many psychological problems involve difficulties with sleep, appetite, touch, digestion, and arousal. Any effective treatment for trauma has to address these basic housekeeping functions of the body.
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Many of my patients respond to stress not by noticing and naming it but by developing migraine headaches or asthma attacks. 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 non-traumatized peers.)
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Many traumatized people find themselves chronically out of sync with the people around them. Many traumatized individuals are too hyper-vigilant to enjoy the ordinary pleasure that life has to offer, while others are too numb to absorb the experiences – or to be alert to signs of real danger. When the smoke detectors of the brain malfunction, people no longer run when they should be trying to escape or fight back when they should be defending themselves. Some people find comfort in groups where they can replay their combat experiences, rape, or torture with others who have a similar backgrounds or experiences. Focusing on a shared history of trauma and victimization alleviates their searing sense of isolation, but usually at the price of having to deny their individual differences. Members can belong only if they conform to the common code.
Isolating oneself into a narrowly defined victim group promotes a view of others as irrelevant at best and dangerous at worst, which eventually only leads to further alienation. 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. They rarely foster the mental flexibility needed to be fully open to what life has to offer and as such cannot liberate their members from their traumas. Well-functioning people are able to accept individual differences and acknowledge the humanity of others.
In the past two decades it has become widely recognized 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 and even dolphins offer less complicated companionship while providing the necessary sense of safety. Dogs and horse, in particular are now extensively used to treat some groups of trauma patients.
STORIES TO INSPIRE
If we understand that traumatized children and adults get stuck in fight-flight or in chronic shut-down, how do we help them to de-activate the defensive maneuvers that once ensured their survival?
Steve Gross used to run the play program at the Trauma Center. Steve often walked around the clinic with a brightly colored beach ball, and when he saw angry or frozen kids in the waiting room he would flash them a big smile. The kids rarely responded. Then, a little later, he would return and “accidentally” drop his ball close to where a kid was sitting. As Steve leaned over to pick it up, he’d nudge it gently toward the kid, who’d usually give a halfhearted push in return. Gradually Steve got a back-and-forth going, and before long you’d see smiles on both faces.
From simple, rhythmically attuned movements, Steve had created a small, safe place where the social-engagement system could begin to re-emerge. In the same way, severely traumatized people may get more out of simply helping to arrange chairs before a meeting or joining others in tapping out a musical rhythm on the chair seats than they would from sitting in those same chairs and discussing the failure in their life.
Sadly, our educational system, as well as many of the methods that profess to treat trauma, tend to bypass this emotional-engagement system and focus instead on recruiting the cognitive capacities of the mind. Despite the well-documented effects of anger, fear, and anxiety on the ability to reason, many programs continue to ignore the need to engage the safety systems of the brain before trying to promote new ways of thinking. The last things that should be cut from school schedules are chorus, physical education, recess, and anything else involving movement, play, and joyful engagement. When children are oppositional, defensive, numbed out, or enraged, it’s also important to recognize that such “bad behaviors” may repeat action patterns that were established to survive serious threats, even if they are intensely upsetting or off-putting.
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I heard a presentation by Steven Maier of the University of Colorado who had collaborated with Martin Seligman of the University of Pennsylvania. His topic was learned helplessness in animals. Maier and Seligman had repeatedly administered painful electric shocks to dogs who were trapped in locked cages. They called this condition “inescapable shock.” Being a dog lover, I realized that I could never have done such research myself, but I was curious how this cruelty would affect the animals.
After administering several courses of electric shock, the researchers opened the doors of the cages and then shocked the gods again. A group of control dogs who had never been shocked before immediately ran away, but the dogs who had earlier been subjected to inescapable shock made no attempt to flee, even when the door was wide open – they just lay there, whimpering and defecating. The mere opportunity to escape does not necessarily make traumatized animals, or people, take the road to freedom. Like Maier and Seligman’s dogs, many traumatized people simply give up. Rather than risk experimenting with new options they stay stuck in the fear they know.
I was riveted by Maiers’ account. What they had done to these poor dogs was exactly had happened by my traumatized human patients. They, too, had been exposed to somebody or something who had inflicted terrible harm on them – harm they had no way of escaping. I made a rapid mental review of the patients I had treated. Almost all had in some way been trapped or immobilized, unable to take action to stave off the inevitable. Their fight/flight response had been thwarted, and the result was either extreme agitation or collapse.
Confrontation with the reality that there is nothing one can do to stave off the inevitable leads to “learned helplessness” a phenomenon that is critical for understanding and treating traumatized and humiliated human beings.
I missed my plane that day because I had to talk with Steve Maier. His workshop offered clues not only about the underlying problems of my patients but also potential keys to their resolution. For example, he and Seligman had found that 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. I wondered if we also could help my patients with their fundamental orientation that there was nothing they could do to defend themselves? Did my patients also need to have physical experiences to restore a visceral sense of control? What if they could be taught to physically move to escape a potentially threatening situation that was similar to the trauma in which they had been trapped and immobilized?
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[Dr. van der Kolk does a more than admirable job tracing the history of treating trauma. Here’s just one flavor of that – the “drug revolution.”]
In 1985, Kings College professor Jeffrey Gray gave a talk about the amygdala, a cluster of brain cells that determines whether a sound, image, or body sensation is perceived as a threat. Gray’s data showed that the sensitivity of the amygdala depended, at least in part, on the amount of the neurotransmitter serotonin in that part of the brain. Animals with low serotonin levels were hyper-reactive to stressful stimuli like loud sounds, while higher levels of serotonin dampened their fear system, making them less likely to become aggressive or frozen in response to potential threats.
That struck me as an important finding. My patients were always blowing up in response to small provocations and felt devastated by the slightest rejection. I became fascinated by the possible role of serotonin in PTSD.
On Monday, February 8, 1988, Prozac was released by the drug company Eli Lilly. The first patients I saw that day was a young woman with a horrendous history of childhood abuse who was now struggling with bulimia – she basically spent much of her life bingeing and purging. I gave her a prescription for the brand-new drug, and when she returned on Thursday she said “I’ve had a very different last few days. I ate when I was hungry, and the rest of the time I did my schoolwork.’ This was one of the most dramatic statements I had ever heard in my office.
On Friday, I saw another patient to whom I’d given Prozac the previous Monday. She was a chronically depressed mother of two school-aged children, preoccupied with her failures as a mother and wife and overwhelmed by demands from the parents who had badly mistreated her as a child. After four days on Prozac, she asked me if she could skip her appointment the following Monday, which was Presidents’ Day. “After all,” she explained, “I’ve never taken my kids skiing – my husband always does – and they are off that day. It would really be nice for them to have some good memories of us having fun together.”
“This was a patient who had always struggled merely to get through the day. After her appointment, I called someone I knew at Eli Lilly and said,” You have a drug that helps people to be in the present, instead of being locked in the past.” Lilly later gave me a small grant to study the effects of Prozac on PTSC in sixty-four people – the first study of the effects of this new class of drugs on PTSD.
Prozac worked significantly better than the placebo for the patients from the Trauma Clinic. They slept more soundly; they had more control over their emotions and were less preoccupied with the past than those who received a sugar pill. Surprisingly, however, the Prozac had no effect at all on the combat veterans at the VA – their PTSD symptoms were unchanged. These results have held true for most subsequent pharmacological studies on veterans: While a few have shown modern improvements, most have not benefited at all. I have never been able to explain this.
Nonetheless, medications such as Prozac and related drugs like Zoloft, Celexa, Cymbalta, and Paxil, have made a substantial contribution to the treatment of trauma-related disorders.
It did not take long for pharmacology to revolutionize psychiatry. Drugs gave doctors a greater sense of efficacy and provide d a tool beyond talk therapy. Drugs also produced income and profits. Grants from the pharmaceutical industry provided us with laboratories filled with energetic graduate students and sophisticated instruments. Psychiatry departments, which had always been located in the basements of hospitals, started to move up, both in terms of location and prestige.
The drug revolution that started out with so much promise may in the end have done as much harm as good. The theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs has become broadly accepted, by the media and the public as well as by the medical profession. In many places drugs have displaced therapy and enabled patients to suppress their problems without addressing the underlying issues. Antidepressants can make all the difference in the world in helping wot day-today functioning, and if it comes to a choice between taking a sleeping pill and drinking yourself into a stupor every night to get a few hours of sleep, there is no question which is preferable. For people who are exhausted from trying to make it on their own through yoga classes, workout routines, or simply toughing it out, medications often can bring life-saving relief. The SSRIs can be very helpful in making traumatized people less enslaved by their emotions, but they should only be considered adjuncts in their overall treatment.
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.
Over the past three decades psychiatric medications have become a mainstay in our culture, with dubious consequences. Consider the case of antidepressants. If they we indeed as effective as we have been led to believe, depression should by now have become a minor issue in our society. Instead, even as antidepressant use continues to increase, it has not made a dent in hospital admissions for depression. The number of people treated for depression has tripled over the past two decades. And one in ten American now take antidepressants.
Because drugs have become so profitable, major medical journals rarely publish studies on non-drug treatments of mental health problems. Practitioners who explore treatments are typically marginalized as “alternative.” Mainstream medicine if firmly committed to a better life through chemistry, and the fact that we can actually change our own physiology and inner equilibrium by means other than drugs is rarely considered.
The brain-disease model overlooks four fundamental truths:
1) Our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring well-being.
2) Language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding a common sense of meaning.
3) We have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through such basic activities as breathing, moving, and touching,
4) We can change social conditions to create environments in which children and adults can feel safe and where they can thrive.
When we ignore these quintessential dimensions of humanity we deprive people of ways to heal form trauma and restore their autonomy. Being a patient, rather than a participant in one’s healing process, separates suffering people from their community and alienates them from an inner sense of self. Given the limitations of drugs, I started to wonder if we could find more natural ways to help people deal with their post-traumatic responses.
[Which the last 200 pages of The Body Keeps the Score is devoted to. Highlights in Exercises to Practice below.]
EXERCISES TO PRACTICE
[Dr. van der Kolk has been a tireless advocate for re-focusing efforts to treat trauma from medicating or palliating symptoms to directly accessing and shifting the root causes of continued pain and suffering.]
“Talking, understanding, and human connections help people gain control over the residues of past trauma and return to being masters of their own ship. But we also see that the imprints from the past can be transformed by having physical experiences that directly contradict the helplessness, rage, and collapse that are part of trauma, and thereby regaining self-mastery.”
[Dr. van der Kolk devotes entire chapters to the effectiveness of major therapeutic modalities like EMDR, Internal Family Systems, and Sensorimotor Psychotherapy for “limbic system therapy since emotional regulation is the critical issue in managing the effects of trauma and neglect.”
And because “at the core of recovery is self-awareness” he focuses a lot as well on the power of mindfulness, yoga, breathwork, bodywork, and journaling to help people “monitor and modify” their responses to traumatizing events.
Dr. van der Kolk also advocates for many “alternative” methods for treating trauma, ranging from art, dance and theater to neurofeedback.
Here I’m offering a technique psychomotor therapy developed by Albert Pesso, new to me but it makes all the sense in the world, to rewire the inner map of one’s self that was impacted by the neglect, betrayal, abandonment of early developmental trauma. Something like psychodrama, the therapist creates a tableau of the client’s past. Group participants play the roles of significant people in the client’s life, such as parents and other family members, so that the client’s inner world begins to take form in three-dimensional space. Group members are also enlisted to play the ideal, wished-for parents who would provide the support, love, and protection that had been lacking at critical moments. Clients become the directors of their own plays, creating around them the past they never had; they often experience profound physical and mental relief after creating these imaginary scenarios.
Here I’m sharing Dr. van der Kolk’s own experience working with Albert Pesso.]
I’d spent several years in psychoanalysis, so I did not expect any more revelations. I was a settled professional man in my forties with my own family, and I thought of my parents as two elderly people who were trying to create a decent old age for themselves. I certainly did not think they still had a major influence on me.
Since there were no other people available for role-play, Al began by asking me to select an object or a piece of furniture to represent my father. I chose a gigantic black leather couch and asked Al to put it upright about eight feet in front of me, slightly to the left. Then he asked if I’d like to bring my mother into the room as well, and I chose a heavy lamp, approximately the same height as the upright couch. As the session continued, the space became populated with the important people in my life: my best friend, a tine Kleenex box to my right; my wife a small pillow next to him; my two children, two more tiny pillows.
After a while I surveyed the projection of my internal landscape: two hulking, dark, and threatening objects representing my parents and an array of minuscule objects representing my wife, children, and friends. I was astounded. I had re-created my inner image of my stern Calvinistic parents from the time I was a little boy. My chest felt tight, and I’m sure that my voice sounded even tighter. I could not deny what my spatial brain was revealing. The structure had allowed me to visualize my implicit map of the world.
When I told Al what I had just uncovered, he nodded and asked if I would allow him to change my perspective. I felt my skepticism return, but I like Al and was curious about his method, so I hesitantly agreed. He then interposed his body directly between me and the couch and lamp, making them disappear from my line of sight. Instantaneously, I felt a deep release in my body – the constriction in my chest eased and my breathing became relaxed. That was the moment I decided to become Pesso’s student.
[Many, many clinicians are writing about trauma these days. These books are some of the most relevant to “normal” folks with “normal” trauma.]
101 Trauma-Informed Interventions: Activities, Exercises and Assignments to Move the Client and Therapy Forward by Linda Curran. PESI, 2013.
Attachment-Focused EMDR: Healing Relational Trauma by Laurel Parnell. New York, Norton, 2013.
The Emotional Life of Your Brain: How Its Unique Patterns Affect the Way You Think, Feel, and Live – and How You Can Change Them by Richard Davidson and Sharon Begley. New York: Hachette, 2012.
In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness by Peter Levine. Berkeley, North Atlantic, 2010.
Mindsight: The New Science of Personal Transformation by Daniel Siegel. New York Norton, 2010.
The Neuroscience of Psychotherapy: Healing the Social Brain by Louis Cozolino. New York, Norton, 2010.
Trauma and the Body: A Sensorimotor Approach to Psychotherapy by Pat Ogden and Kekuni Minton. New York, Norton, 2008.
Working with Children to Heal Interpersonal Trauma: The Power of Play by Lenore Terr. Ed. Eliana Gil. New York: Guilford Press, 2011.