The Body Keeps The Score

A Conversation with Bessel van der Kolk

Q. You’ve been working with traumatized children and adults for many years and have seen significant changes in how mental illness and trauma are treated. What have you learned from neuroscience, attachment research, and interpersonal neurobiology about how to help children and adults recover from toxic stress?

A. Trauma is ubiquitous in our society. Over 500,000 children are reported for abuse and neglect each year. One out of four Americans reports having been left with bruises after having been hit as a child, one out of five was sexually molested, one out of eight has witnessed severe domestic violence, and a a quarter grew up with alcoholism or drug addiction. Almost every inmate in our prison system, by far the largest in the world, has a serious history of prior trauma. Half a million women are raped each year, half of them before they are adolescents.

These experiences leave traces on people’s biology and identity and have devastating social consequences–medical illnesses, problems with school and work performance, drug addiction and a variety of psychiatric illness. In fact, the Centers for Disease Control and Prevention calculate that childhood trauma is our single largest public health issue—more costly than cancer or heart disease—and one that is largely preventable by early prevention and intervention.

In order to overcome trauma people need to feel safe enough to open up their hearts and minds to others and become engaged with new possibilities. This can only be done if trauma survivors, and their communities, are helped to confront and confess the reality of what has happened and are helped to feel safe again. In many non-Western cultures this involves communal rhythmical activities, such as dancing, athletics, and collective prayer. Communal rituals of acknowledgment, support, and repentance can play a substantial role in healing from trauma.

Treatments that focus solely on decreasing a few PTSD symptoms, or on drugs to obliterate feelings, ignore the importance of integrating the traumatic experience in the overall arc of one’s life, and they fail to help survivors reconnect with their communities. The scientific evidence for the efficacy of these therapies, while widely promulgated and practiced, is, in fact, quite disappointing.

Probably the most important challenge in recovering from trauma is learning to regulate oneself. We can activate this innate capacity by utilizing breath, touch, movement, and rhythmical engagement with one’s fellow human beings, such as yoga, tai chi, and dancing, methods that are not widely utilized in medical settings or in school systems.

Q. In your book you talk about the effect of trauma on the brain. What changes occur in the brain in response to trauma? What happens when someone experiences a flashback?

A. Neuroscience research has shown that traumatized individuals are prone to activate brain areas involved in fear perception, and to have deficits in the areas involved in filtering out relevant from irrelevant information, as well as in the perception of bodily sensations. These changes do not occur in the rational part of the brain, and do not really seem to benefit merely from being aware of the error of one’s ways.

The impact of trauma is located in the survival part of the brain, which does not return to baseline after the threat is over. This part of the brain is by definition unreasonable—you do not stop being hungry by reminding yourself how fat you are, and it’s pretty difficult to talk yourself out of being angry, shut down, or in love.

One of the most devastating effects of trauma is that people’s biology changes into a biology of threat; this is expressed on multiple levels, in stress hormones, immunology and what the brain selects to pay attention to. The intrinsic reward system changes, as do “attractors”—what turns you on or leaves you cold. As a consequence, traumatized people stay on hyper alert; they feel chronically unsafe and in danger, and they have problems feeling calm and enjoying the moment and they are out of touch with their surroundings. Trauma can make it difficult to have comfortable reciprocal relationships with one’s children, partners, and coworkers.

Through brain imaging technology, we can visualize how traumatized people even have problems processing ordinary, nonthreatening information, which makes it difficult to fully engage in daily life and to learn from experience. As a result, they are frazzled, unfocused, and tend to repeat the same nonproductive behavior patterns, with the same miserable results.

Trauma affects the entire human organism–thinking, feeling, relationships, and the housekeeping of one’s body. Trauma survivors are vulnerable to a host of medical illnesses and chronic pain syndromes, insomnia, drug and alcohol addiction, depression, obesity, and other issues related to optimal functioning of the entire organism, and the capacity for self regulation and self-care.

Q. What do you wish more people understood about trauma?

A. First of all, is important to understand is how ubiquitous trauma is in our society, what devastating effects it has on family life, workplace productivity, the facility to learn and take initiative, the ability to stay calm and focused, and the capacity to be compassionate with one’s fellow man.

As a society we cannot afford to ignore trauma and keep our heads in the sand. There are, in fact, countries where governments have taken the science of trauma (and its prevention and treatment) seriously, with results to prove how well that works. For example, Norway has fifty-one citizens per hundred thousand in jail; the US, 951. Their students also have higher test scores and higher graduation rates from high school and college, and their society has a fraction of our crime rate.

I think that the general public tends to associate trauma with the military and terrorism, but the vast majority of traumas occur within families, schools, and neighborhoods, the very people whom they depend on for safety and security. Most traumatized women and children, for example, are traumatized by their intimates. Another important issue is that trauma has a different impact, depending on the age and relative maturity of the affected individual. The brains of traumatized kids develop in a “use-dependent” manner—they become experts in dealing with threat, and have problems with self-regulation, play, and the sort of imaginative creativity that is necessary to become productive members of society.

Trauma is a deeply communal problem: we are fundamentally social animals, and trauma profoundly affects people’s capacity to get along with others and be a cooperative and enjoyable member of the tribe.

Q. You have worked with war veterans and at the beginning of your career worked with Vietnam vets before PTSD was an official diagnosis. What do you think of the current prescribed treatment by the Veteran Affairs office for trauma?

A. I currently treat only a few veterans and I am not intimately familiar with what is happening at the Veterans Administration. The VA is a pretty closed system—people who work at the VA rarely attend my workshops or lectures, or those of my close colleagues.

I hear that their main focus is on cognitive behavioral treatments, and on desensitizing people to their memories. These treatments, research shows, are not particularly effective. That is not surprising, given that being traumatized is not an issue of faulty cognition—the problems emanate from parts of the brain that have little to do with cognition.

The biggest problem for veterans is to fully engage in their current lives. The Body Keeps the Score provides a number of ways to reengage — some are ancient, like yoga, theater, and martial arts, while others, like neurofeedback, are based on the latest advances in neuroscience.

Doctors at the VA and the DoD prescribe vast amounts of drugs, even though there is scant evidence that drugs significantly help traumatic stress. Drugs can obscure posttraumatic symptoms but not resolve them.

This issue is even more concerning in the treatment of traumatized children. The poorer you are the more likely it is that you will be given psychiatric drugs to control your behavior. These drugs can have devastating effects on children’s capacity to learn, engage and feel good in their bodies.

Q. What benefits does yoga offer patients in treatment? Are they universal?

A. Yoga is just one of many time-honored ways to help people experience ownership of their bodies and to feel safe and in control. Our most recent research study on this subject showed that yoga had better results than any drug studies so far for PTSD. That is not to say that everybody should practice yoga—one size never fits all—but every trauma survivor would do well to engage in practices that increases their inner bodily sense of control, safety, and flexibility.

In order to overcome trauma we have to befriend and be in touch with ourselves—our sensations and our emotions. Neuroscience research has shown that the only way we can consciously access that disturbed survival brain is through our interoceptive pathways — through the part of the brain that helps us to feel what is going on deep inside of ourselves.

Q. What do you hope to accomplish with The Body Keeps the Score? What do you want readers to take away from it?

A. I hope that all traumatized individuals, and their loved ones, will find this book helpful for comfort, understanding, and guidance. That politicians and policy makers will read this book to help them understand the devastating effects of early deprivation and punitive school systems on the health and welfare of our country, as well as the predictable consequences of putting our young men and women in harm’s way.

That parents of adopted kids will understand what their children are dealing with, and serve as a guide to solutions.

That educators and school systems will implement trauma-based interventions for children who come from abuse and neglect, and thereby become agents of change to help all children become productive members of society. My greatest hope is that all school systems will teach the four R’s: reading, writing, rhythmatic, and self-regulation. That from K to 12 all kids will be taught to experience how they can regulate themselves though their breath, movements, and synchronized interactions with others, and learn how their bodies, brains, and minds react to overwhelming stress with recognizable patterns that can be managed through self-regulation practices, more than with drugs or alcohol.

That it will inspire our armed forces to become as expert in helping returning warriors to once again become peaceful and productive civilians, as they are in transforming adolescents into members of magnificent fighting units.

That physicians will appreciate the role of trauma in the disintegration of bodily systems, and learn what they can do about it.

That mental health professionals will acknowledge the relationship between trauma, drug addiction, and numerous psychiatric “disorders” and incorporate effective trauma treatments in their practice.

That law enforcement and criminal justice personnel will read it to understand their own responses, and that of the people they are dealing with.

That psychiatrists will integrate the scientific knowledge that our brains are meant to help us cooperate and thrive in a community, and realize that their job is to help patients deal with the devastating effects of trauma on mind, brain, and body.

I hope that this book will help us all acknowledge the fact that our zip code has a more profound effect on health and well-being then our genetic code. In short, the goal of this book is to help us to become a trauma-informed society that will confront and deal with our largest public health issue: psychological trauma.